Inspection on 26/04/05 for Thistleton Lodge Care Home

This inspection was carried out on 26th April 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Thistleton Lodge Care Home 19/04/07

Thistleton Lodge Care Home 25/10/06

Thistleton Lodge Care Home 14/10/05

Thistleton Lodge Care Home 01/02/05

Thistleton Lodge Care Home 02/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Thistleton Lodge Care Home Fleetwood Road Thistleton, Near Kirkham Lancashire PR4 3YA Lead Inspector Patrick Rooney Unannounced 26th April 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. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Thistleton Lodge Care Home Address Fleetwood Road, Thistleton, Nr Kirkham, Lancashire. PR4 3YA 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) 01995 671088 Thistleton Lodge Limited Lorna Joy Gardner CRH Care Home 56 Category(ies) of DE Dementia 26, OP Old Age 30 registration, with number of places Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. The home may accommodate 30 service users in the category of old age (OP) and 26 service users in the dementia (DE) category. The maximum number of service users who can be accommodated at any one time must not exceed 56. Date of last inspection 1st February 2005 Brief Description of the Service: Thistleton Lodge Care Home is a very large detached property in its own grounds situated on the main Fleetwood road near to Kirkham. It is easily accessible and there is ample car parking space for visitors.The home provides care for up to 58 service users incorporating residential, respite and dementia care on the ground and first floors.Accommodation is in single and double rooms; each bedroom complies with minimum space requirements.There are four lounge areas and a conservatory. The lounge areas incorporate dining space and there is a separate dining room on the ground floor.There is a passenger lift and access for wheelchairs throughout. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over a period of one day. The information contained in this report was obtained from discussion with the registered manager, interviews and informal discussion with staff. The inspector also chose four residents files to look at and tracked their care. He also spoke to visiting relatives and has received questionnaires from relatives and residents. The inspector also had lunch with residents in the dining room. A tour of the premises took place and health and safety records were seen. Staff records were examined including CRB and POVA checks. Since the last inspection, which took place on 1 February 2005 there have been no complaints received regarding the home. What the service does well: The home has a well established group of staff that provide care and support for residents. The inspector was able to confirm this from observation, discussion with residents and staff. The four residents whose care was tracked confirmed they are provided with the care they need. One resident told the inspector that the staff provide good care and more. Meals are varied and there are plenty of choices. The inspector took part in the lunch time meal with residents and observed this to be the case. There were choices available and the meal was of good quality and well presented. Residents said that the food they receive is very good and they are able to ask for alternatives if they wish. Mealtimes are flexible according to the needs of residents. Meals may be taken their own rooms if residents wish. It was observed that one resident who had difficulty in eating was able to take their meal privately to preserve dignity. The home employs two diversional therapists with specialist experience in providing activities. The inspector observed an activities session in the first floor dementia unit. This took the form of a quiz linked to reminiscence themes. Those taking part were thoroughly enjoying the experience. One resident whose care plan identified a like to be involved in helping around the home is encouraged in this. The home places importance on providing training for staff. New staff complete the TOPPS induction course. Records of this were seen during the Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 6 inspection. Nine staff have completed NVQ 2 and four are currently undertaking this training. Staff have also received training in dementia care and challenging behaviour. The inspector saw an on going programme for the provision of this training. What has improved since the last inspection? What they could do better: The home could provide better systems to ensure personal care records are kept securely and train staff in the importance of this. As it was found during the inspection that staff do not keep care plans in a safe and secure place after working on them. Therefore there is a risk that residents personal information may be seen by persons who should not have access to these records. Ventilation and effective extractor systems need to be provided in the smoking lounges. Communal areas in the home where residents are able to smoke. These areas are not currently fitted with extractor fans to ensure good ventilation. These areas were observed to be very smoky during the inspection. The exterior fabric of the home requires attention to bring it up to standard. The outside of the building looks to be in need of building work and decoration. Please contact the provider for advice of actions taken in response to this Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 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 standard(s) 1 and 3 The admission and assessment procedures seen during the inspection were clear and ensure the care needs of residents are identified. EVIDENCE: Service users are provided with a service users guide, which informs them of services offered by the home. Individual records are kept for each service user which details their assessment needs and their care plans. The inspector tracked the care of four residents from their initial assessments to their care plans. He also spoke to service users about their care plans and the care they receive. They were able to tell the inspector about their individual care needs which had been recorded. One recently admitted resident described the care as “super” stated that all care needs are met and more. Staff members spoken to demonstrated an awareness of the care needs of residents and the review procedure for each individual. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 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) 7,8,9 and 10 Promotion of health and personal care is taken seriously and residents welfare is monitored and health needs met. Requirements made in the last inspection regarding safe administration of drugs have been implemented. EVIDENCE: Care records examined for four residents clearly describe their health needs including risk assessments. Medication records were clear and up to date, staff records showed that staff administering medication receive training in safe handling and administration of medication. Staff demonstrated a good awareness of policies and procedures in relation to giving out medication. Surveys carried out by the home indicated that staff perform personal care tasks in a respectful dignified manner protecting residents privacy. Residents spoken to told the inspector they are treated with dignity and respect and that their privacy is maintained. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 11 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 and 15 Social activities are provided which are varied according to the needs of individual service users. Dietary needs of residents are well catered for and there are a choice of meals available to meet individual needs. EVIDENCE: There are two diversional therapists employed to plan and deliver activities for residents on both the units in Thistleton Lodge. Individual hobbies and interests are recorded in individual files. The inspector observed an activity session in the dementia unit, which had been devised to stimulate the memories of those taking part. Those taking part were enjoying the session. There was a record of activities available for both units, which showed a variety of activities and outings on offer. Residents spoken to said they felt there were plenty of activities available which they had a choice of taking part in. Comment cards were received from 14 residents all of these were positive. One resident described the home as the best place they had ever been to. The inspector saw a record of menus provided to residents. Individual dietary needs form part of assessments and care plans and were seen in residents records. Records showed a variety of nutritional food on offer with choices available. The inspector had a meal with residents, this was of good standard and well presented, choices were offered. Residents told the inspector the food was good and they were offered choices. During the meal it was Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 12 observed that a resident requested a salad instead of the meal on the menu, this was duly provided. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 13 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) 16 and 18 Arrangements for complaints are good and an effective whistle blowing policy ensures protection of residents. EVIDENCE: The home has a detailed complaints procedure. Staff spoken to were able to explain the process, residents spoken to were aware of the procedure which is provided in their service users guide. A record of internal complaints is kept and outcomes recorded. There has been no complaint made to the CSCI since the last inspection. There is a procedure available to protect residents from abuse including a whistle blowing policy. Staff interviewed demonstrated an awareness and understanding of these policies. This was confirmed recently when an adult abuse investigation was triggered by staff at the home, and the prompt reporting of this by management to Social Services and the CSCI. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 14 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) 19,25 &26 The standard of furnishings and decoration are reasonable and provide a homely environment which is clean and homely. The exterior of the home needs refurbishment. The upstairs smoking lounge was not ventilated adequately thus compromising the health and safety of residents and staff. EVIDENCE: The inspector carried out a tour of the dinning areas and saw 4 residents in their own rooms. Internally standards of decoration and furnishings were good and comfortable. Residents told the inspector they felt their surroundings are homely and comfortable. The first floor smoking lounge was very smoky as there was no extractor fan in place to clear the smoke. The inspector observed the exterior of the building and found paint work was flaking and some windows were rotten and in need of replacement. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 15 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 and 29 The policy and procedures for the recruitment and training of staff are robust and provide safeguards which protect residents. The number of staff on duty was sufficient to meet the needs of residents living at the home. EVIDENCE: The inspector saw four staff files all contained the necessary recruitment forms and checks to ensure the protection of residents. These include an application form, two references a POVA and CRB check. Induction and training records were seen and showed all staff receive an induction and training in providing care. Most of the staff working on the dementia unit have received training in dementia care and further training is being made available. Records also showed that nine out of 24 care staff are trained to NVQ 2 and five are currently undertaking this training. Five staff were interviewed and confirmed they receive induction and training. Rotas examined showed that there are sufficient staff on duty to meet the needs of residents. Sufficient staff were observed to be on duty at the time of the inspection. Residents spoken to told the inspector staff are caring pleasant and helpful. One resident told the inspector that staff provide all care required and more. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 16 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) 33,35,37 and 38 Management of Thistleton Lodge has improved during the past year there is leadership, guidance and continuity for residents and staff who told the inspector that that they are aware of the management structure. Care plan records should be kept more securely, management of the home must make more effort to ensure residents confidentiality. There are Health and Safety policies and procedures in place, however as pointed out in Environmental Standards the smoking lounge situated in the dementia unit had no extractor fan and was very smoky posing a risk to health and safety of residents and staff. Management must ensure residents health and welfare is protected. EVIDENCE: Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 17 The registered manager has worked in a senior capacity at the home for several years, she is a qualified nurse and during the past year has achieved the Registered Managers Award. Staff and residents spoken to said management was open an approachable. The manager or her deputy is available to residents in the home on a daily basis, this was confirmed by residents who described management as helpful. During the course of the inspection the inspector found one residents care records in the corridor of the ground floor unit and another residents care records in the first floor lounge. On each occasion these records were unattended and available to anyone to pick them up. The smoking lounge was observed to be smoky and without an extractor fan. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 18 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 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x 2 2 Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 19 NO 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 19 and 38 Regulation 13(4)(a) Requirement The registered provider must ensure that all smoking lounges have and adequate ventilation and extractor system. There must be a system in place to ensure all records including care plans are kept securely at all times. Timescale for action 1/8/05 2. 37 17(1)(b) 20/6/05 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 19 Good Practice Recommendations It is reccomended that external fabric of the building is refurbished. Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 2nd Floor, Unit 1 Tustin Court, Portway Preston PR2 2YQ 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 Thistleton Lodge Care Home F57-F09 S6089 Thistleton Lodge Care Home V217587 260405 Stage 4.doc Version 1.30 Page 21 - 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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