Inspection on 24/05/07 for Thistle Hill Hall

This inspection was carried out on 24th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Thistle Hill Hall 12/08/09

Thistle Hill Hall 15/06/06

Similar services:

Trevayler Residential Care Home

Thornham Grove

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

Brain Injury Services, 51 The Drive

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Thistle Hill Hall Debdale Specialist Care Limited Debdale Lane Mansfield Woodhouse Nottinghamshire NG19 7EZ Lead Inspector Rob Cooper Unannounced Inspection 24th May 2007 10:00 Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 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 Thistle Hill Hall DS0000063549.V337278.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 and 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. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thistle Hill Hall Address Debdale Specialist Care Limited Debdale Lane Mansfield Woodhouse Nottinghamshire NG19 7EZ 01623 655100 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) www.debdalecare.co.uk Debdale Specialist Care Ltd Mrs Susan Lepori Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named Service User to be admitted above the age of 65. Service User shall be in Category MD. Date of last inspection 16th March 2007 Brief Description of the Service: Thistle Hill Hall is a Grade II listed building, which provides residential care for adults who have enduring mental health problems. The accommodation is situated on two floors with the upper floor being accessed via stairs or a passenger lift. The accommodation is spacious with high quality fixtures and fittings, and is tastefully decorated throughout, while still incorporating many of the original features from the building’s past. Outside there are ample grounds much laid to lawn, although an abundance of shrubs and trees add to the privacy of the house. To the front of the building is a small car park for staff and visitors. All bedrooms have en-suite facilities, and there are two training kitchenettes as well as a central kitchen and dining room. On site, there is a gymnasium, as well as a hobbies/games room, with table tennis, pool and a variety of tabletop games and activities. Thistle Hill Hall has two lounges, a visitor’s room, and ample bathrooms and toilets in addition to the en-suite facilities. These bathrooms are spacious, and a person with mobility difficulties could be accommodated. Fees: Range between: £1,400 & £2,900 per week Thistle Hill Hall DS0000063549.V337278.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 inspection site visit as part of the key inspection process – so that no one at Thistle Hill Hall knew that the inspection was going to take place. The visit took approximately three and a half hours through the middle of the day, with one inspector present. The method used to carry out this key inspection was to send out a preinspection questionnaire, which asked questions about the service, to gather statistics, such as how many service users there are, the numbers of staff etc. We also sent out a number of surveys to residents and relatives, of which six had been returned from residents and three from relatives. We also sent Thistle Hill Hall an Annual Quality Assurance Assessment (known as an AQAA) for them to self assess their service, this was completed and returned before the inspection site visit and helped inform the judgements. This was followed with an inspection site visit to Thistle Hill Hall, where a method called case tracking was used; this involved identifying three residents and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was done by a partial tour of Thistle Hill Hall, looking at the activities on offer, and talking to three residents and four members of staff about the quality of the service, and their experiences of living and working at Thistle Hill Hall. The registered manager Sue Lepori supplied much of the information during the inspection site visit. On the day of this inspection there were sixteen residents in residence (including one in hospital). Since the last key inspection in June 2006 one random inspection has taken place, this was in March 2007, and was in response to concerns raised by a resident at Thistle Hill Hall. The outcome of this random inspection was that the resident’s concerns were found to be groundless. Prospective residents can also obtain information about Thistle Hill Hall from their web site at: www.debdalecare.co.uk This web site also has a number of links, including a link to the Commission for Social Care inspection’s web site where previous inspection reports for Thistle Hill Hall can be viewed. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: No requirements or recommendations have been made as a result of this key inspection, and Thistle Hill Hall should try to maintain the standards that they have set in the last twelve months. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12&5 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. Prospective residents at Thistle Hill Hall had sufficient information before they moved in to make an informed choice about where to live. Currently residents are well informed about the services Thistle Hill Hall offers. EVIDENCE: Both the statement of purpose and service user guide for Thistle Hill Hall were seen. Both documents contained all of the information, which Care Homes Regulations say that they should. Both documents were written in an easy to understand style, and contained photographs to illustrate them further. The web site for the home is very informative, and contains important information about the services on offer at Thistle Hill Hall this includes photographs and Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 10 up-to-date information about ongoing developments, such as the refurbishment of the gym. Three resident’s files were seen as part of the case tracking process, each file contained a range of different assessment tools, covering areas such as: Resident’s dependency assessments, continence assessments, monthly nutritional risk assessments, moving and handling assessments and risk assessments leading to assessments of areas of concern. Several different professionals have been involved in producing these assessments as Thistle Hill Hall takes a multi-disciplinary approach to its work. A multi-disciplinary approach is one where many different professionals and workers with different area of expertise come together for the good of the resident. Residents who have been admitted as private clients have an individual contract, and copies of the terms and conditions of residence form part of the resident’s welcome pack, and are included in the service user guide. On an individual basis residents will have a behavioural contract with the staff, which will identify and establish some boundaries for living at Thistle Hill Hall. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9 & 10 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Residents at Thistle Hill Hall have their needs assessed, and have an individual plan of care containing information about their needs, and risk assessments to support them in leading an independent lifestyle. EVIDENCE: Each of the three resident’s files that were seen contained a detailed plan of care, which had been produced from assessments and identified personal goals and needs and how to meet them. There was clear evidence that care plans Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 12 were being reviewed, and that changes in resident’s needs were being identified and actioned. Three residents were spoken with, and each one said that they felt they were involved in decision making within their own lives. In addition there were regular meetings with fellow residents and with staff where residents were able to either take decisions of indicate their views as part of the decision making process. Thistle Hill Hall also employ a counsellor who has weekly sessions with residents on a one to one basis, and which helps to contribute to the resident’s decision making. Each of the resident’s files that were seen contained detailed risk assessments and had support plans attached detailing the action that staff should take to minimise risks, while still supporting residents to enjoy an ‘ordinary life’. As identified earlier the risk assessments led to assessments of areas of concern, and were produced on an individual basis, focussing on an individual’s strengths and needs. Many of the residents at Thistle Hill Hall are very sensitive about their personal information, and the staff take issues of confidentiality very seriously, as a result resident’s files were seen to be kept under lock and key, and there are procedures in place to protect resident’s confidentiality. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 & 17 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 14 Residents at Thistle Hill Hall are offered a stimulating range of activities, and are offered a varied nutritious and healthy diet. EVIDENCE: Thistle Hill Hall provides a wide range of activities for its residents. These include a gymnasium with a range of fitness machines, an art room, with a qualified art therapist, helping residents with pottery and creative arts. There is also pool table and table tennis available, as well as close links with local colleges, so that residents are able to access educational courses as well as personal development courses. Discussions with two residents about supported the view that there are lots of activities for residents. As well as using local colleges, Thistle Hill Hall residents spend a lot of time in the local community. On the day of the inspection one resident was visiting Derby in Thistle Hill Hall’s mini bus, while another had gone to the local ASDA for a cup of tea and to do some personal shopping. A third resident was in Mansfield shopping for clothes. There were many photographs of residents out and about in the local community to support the view that residents were actively involved in the local community. Family contact is actively encouraged, and residents whose family are not local, are assisted to stay in touch, where appropriate, with regular trips to their family homes with staff support. Contraception is discussed with residents, and safe sex is promoted through counselling. Thistle Hill Hall has a policy in place, which was seen, and there is a clear understanding that the residents at Thistle Hill Hall are vulnerable adults, and sexual relationships are not encouraged, although it is understood they are consenting adults and have rights in this area. Three resident’s bedrooms were seen and these were well personalised. A number of residents have pets (including a dog) and residents are encouraged to look after their pets, and to learn about responsibility through pet ownership. Residents are expected to clean their own bedrooms and take responsibility for their laundry. There is a lot of emphasis on choice, and the fact that with choice comes responsibility. All residents were registered for postal votes at the last elections, although not everyone chose to exercise their right to vote. There was clear evidence that residents at Thistle Hill Hall are encouraged to take responsibility and exercise choice and control in their daily lives. Thistle Hill Hall has a large central kitchen, which provides the main meals through the day. Evidence was seen in the form of the six-week menu that there is plenty of choice, and the quality of the food is excellent. Four residents when asked about the food said that they thought it was very good, Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 15 and they were very happy with the quality of the food on offer. All four residents said that should they want something different, the kitchen staff would offer a number of alternatives. There are two kitchenettes within the building where residents can make drinks and snacks throughout the day, should they want. Some residents were eating during the inspection visit, and the quality of the food was obviously to a high standard. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 & 20 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Residents at Thistle Hill Hall have their health care well managed, and are supported in a positive manner by the staff. Medication is well managed at Thistle Hill Hall. EVIDENCE: Discussions with four residents showed that they were quite happy with the personal support they were receiving. Residents were able to choose whether they had a bath or a shower – most preferring to use their en-suite shower, but the choice was there. The three resident’s files that were seen as part of Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 17 the case tracking exercise contained details relating to personal choice and preference. Residents are all registered with a local GP surgery, and where a resident has made a number of visits to the local hospital (particularly the accident & emergency department) there was evidence of good relationships and communication between Thistle Hill Hall staff and the hospital. Each of the resident’s files that were seen had care plans specifically related to health care needs, and health professionals including a psychiatrist make regular visits to Thistle Hill Hall to meet with residents and staff. Three residents when asked said that they had no problems related to their health, and if they needed to see a doctor or go to the hospital this was arranged very quickly. Boots (The Chemist) provide Thistle Hill Hall with their medication. An inspection of the storage, and booking in and out procedures showed that medication is handled safely and there is a clear audit trail for medication from the point of ordering to administration and/or disposal. Administration records were inspected and found to be complete. No resident at Thistle Hill Hall currently self-medicates. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. Residents at Thistle Hill Hall are safe, and feel their views are listened to and acted upon. EVIDENCE: Thistle Hill Hall have not received any complaints since the last key inspection, although a number of concerns have been raised with the Commission for Social Care Inspection by one particular resident. These concerns triggered a random inspection in March 2007, but careful consideration found the concerns to be groundless. The complaints procedure is widely available and forms part of the Service User Guide, three residents when asked said that if they were unhappy they knew who to complain to and how to complain, each one was also aware of other agencies (including the Commission for Social Care inspection and Social Services) to whom they could also raise concerns and issues. The experience of the resident who had triggered the random inspection demonstrated that Thistle Hill Hall take an open approach to complaints, and welcome the input of other agencies. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 19 Some of the residents at Thistle Hill Hall have issues relating to self-harm, and evidence was seen within resident’s files that care plans are in place to manage this. Evidence was also seen that care plans and risk assessments are in place at the local Accident & Emergency department, so that should a resident arrive having self-harmed there is a consistent approach. Most of the staff at Thistle Hill Hall have received training in safeguarding adults, and evidence was seen that further courses have been booked in the future. This training is aimed at raising staff awareness of abuse, and through raising the issues, offering residents greater protection against abusive practice. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 26 & 30 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. Thistle Hill Hall is a clean, safe, homely and comfortable care home, with good quality fixtures and fittings. EVIDENCE: Thistle Hill Hall is a Grade II listed building and has been refurbished to a very high standard. It is spacious with every bedroom being a single room with enThistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 21 suite facilities. There are a number of communal rooms, which are decorated to a high standard and which have very good quality fixtures and fittings, and which provide the opportunity for different activities and room for residents to spread out through the house, rather than being pushed together in one or two small areas. Four residents when asked said they thought that Thistle Hill Hall was very comfortable, and that it had very good facilities. Four residents when asked said they thought their bedrooms were very good – all of the bedrooms were en-suite with a toilet and shower, and one was a ‘bedsit’ with additional space, and designed to aid residents in their move towards independence. A partial tour of Thistle Hill Hall showed it to be clean and well maintained. There is a team of housekeeping staff who are responsible for the general cleanliness of the building, and it’s general upkeep. Throughout the building there was a clean and fresh odour and staff were seen cleaning during the inspection. There was also a good range of cleaning materials, and staff said they were quite happy with the cleaning materials provided. Three residents were asked about the cleaning, and both said that it was very good. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 & 36 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. A competent, well-trained and supervised staff team that has been professionally recruited supports residents. EVIDENCE: The staffing rota for Thistle Hill Hall shows that there is a structure through the staff team, and different levels of staff have differing levels of responsibility and accountability. There is a clear management structure in place and two residents who were asked said they were aware of the staffing structure, and organisation. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 23 The care industry considers National Vocational Qualifications (NVQ) to level II in care to be the basic qualification for staff working in residential care. A review of the training records showed that currently there are eight staff with NVQ level II qualifications, a further six are currently studying for their NVQ level II, and four more have their NVQ level III, with four others currently studying for their NVQ level III qualifications. It is recommended that a minimum 50 of the care team are NVQ qualified, and the staff team at Thistle Hill Hall are currently beyond this figure. In addition four members of staff are studying for their NVQ in Team Leading, two are studying for their Registered Managers Award, while another four of the staff are qualified nurses. A review of the staffing rota and staffing levels at Thistle Hill Hall showed that there were enough staff currently employed to meet the resident’s needs. Two residents were asked about staffing levels, and both said that they thought there were enough staff. In addition Thistle Hill Hall employ several other professionals to meet the resident’s needs, such as a trained counsellor, and an art therapist to help the regular staff, this helps to promote independence, and personal choice. Three staff files were seen, and these contained all of the information that would show that staff had been recruited in a safe manner – in that applicants had to fill out an application form, provide two written references and undergo a Criminal Records Bureau check. A review of the documentation showed that there were no issues raised in the recruitment process, and that it was possible to prove the process had worked to protect residents. Discussions with three staff members about their recruitment evidenced that they had undergone preemployment checks, and had not started working until those checks had been completed. A review of the staff training records showed that Thistle Hill Hall does have a training plan for its staff, and that there are staff training courses planned for the coming months. The records showed that staff were receiving the skills training to be able to do their jobs, and discussions with three members of staff supported this view, and provided evidence of the different training courses staff had attended, including training in the mandatory areas – fire, food hygiene etc. This is in addition to the National Vocational Qualification (NVQ) training already identified. Discussions with staff members showed that there was a clear emphasis on providing staff with the skills they need to do their jobs, and ensuring that several staff members have the skill base, rather than a selected few. Records seen evidenced that staff are having regular formal supervision, and that they are being supported within their roles. Discussions with two staff members showed that they have a regular one to one supervision session with a senior member of staff, and that they feel able to raise any issues at these Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 24 sessions. Each member of staff said they felt very well supported and there was good team communication. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 & 42 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Thistle Hill Hall is a safe, well managed, and organised care home, with good recruitment and quality assurance systems in place. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 26 EVIDENCE: The registered manager has been through the Commission for Social Care Inspection’s ‘fit person’ process, and has been judged to be fit to manage a residential care home. Evidence was seen that the manager is suitably experienced and qualified, having been in post since before Thistle Hill Hall opened its doors to residents. The quality assurance system at Thistle Hill Hall has many strands: There are questionnaires for residents and visitors, and residents are encouraged to provide feedback on the quality of the food on a regular basis for example. There are regular residents meetings where residents are encouraged to contribute to the agenda, and regular internal audits of the kitchen, health & safety, and maintenance issues ensure that standards are maintained. During 2007 the Commission for Social Care Inspection introduced Annual Quality Assurance Assessments (AQAA’s), which are self-assessments for services. Thistle Hill Hall has completed their AQAA, and staff members were asked to contribute to the process by the management team. The Thistle Hill AQAA indicates that the staff feel they are offering a quality service. Many different health & safety records were seen, including the fire safety records – weekly tests, emergency lighting tests and extinguisher maintenance records, and the Control of Substances Hazardous to Health (COSHH) records, all were found to be correct and up-to-date, which evidenced that the residents and the staff are living and working in a safe environment. Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 27 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. Where there is no score against a standard it has not been looked at during this inspection. 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 4 2 4 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 4 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 4 34 3 35 4 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 4 40 X 41 X 42 3 43 X 3 4 X 3 3 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thistle Hill Hall Score 3 4 3 X DS0000063549.V337278.R01.S.doc Version 5.2 Page 28 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. Refer to Standard Good Practice Recommendations Thistle Hill Hall DS0000063549.V337278.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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