CARE HOMES FOR OLDER PEOPLE
Thomas House 168 Prescot Road West Park St Helens Merseyside WA10 3TS Lead Inspector
Daniel Hamilton Key Unannounced Inspection 24th July 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Thomas House DS0000022411.V337213.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. 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. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Thomas House Address 168 Prescot Road West Park St Helens Merseyside WA10 3TS 01744 608800 01744 670701 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) Thomas House (St Helens) Limited Mrs Barbara Thornber Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 28 (OP) Date of last inspection 29th June 2006 Brief Description of the Service: Thomas House is a privately run care home situated on Prescot Road in the West Park area of St. Helens. The home is close to local amenities and has good links to public transport and shops. St Helens town centre is approximately one mile away. Thomas House opened in 1997 and is registered for 28 elderly persons. It is a ‘no smoking’ environment. The home is within a large house built in the 1870’s, which has had extensive renovation work done to extend the facilities. Accommodation is on two floors. The home offers three lounges, a library, dining room, treatment room and hairdressing salon. The premises has 24 single rooms with en-suites and 2 double rooms. Toilets and bathroom facilities are located throughout the home. The first floor rooms are accessible via a passenger lift and a call bell system is in place. There are extensive gardens surrounding the home and a small patio area at the rear, which is accessible from the side entrance. Car parking space is available at the front and rear of the home. The Care Home Fee is set at £367.00 to £391.00 per week. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 8.5 hours. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The inspector met with the Owners, Registered Manager, care staff, residents, relatives and a health care professional during the visit. Care Home Survey forms were also distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional feedback about the home. All the core standards were assessed and action taken in response to the previous requirements and recommendations from the last inspection in June 2006 was reviewed. What the service does well:
Residents and visitors spoken with were complimentary of the overall service provided at Thomas House and the care provided. Comments received included; I think everyone is very kind to me and they treat me with respect” and “The staff are nice people. They encourage you to do as much as you can for yourself and are there when needed. They are all considerate people.” The environment was well maintained and had received ongoing investment in order to ensure the home remained comfortable and homely for residents. The home had an assessment and care planning system in operation to ensure the needs of prospective residents were identified and planned for. The healthcare needs of the people living in the home were monitored and arrangements had been made for residents to access medical practitioners subject to need. One resident reported; “I think the staff look after our health needs very well.” Likewise, a health care professional spoken with during the visit stated; “End of life care is also good. Appropriate support is provided to residents and their families.” Daily life, social activities and meals were well managed. The routines in the home were observed as being based around the needs and preferences of the people living in the home and a monthly programme of activities had been developed for residents. Comments received from residents included; “I’m pleased with the home. I can’t say anything bad about it. I am free do as I wish within reason”; “There are enough activities for me. It’s easy going and you can choose whether to join in or not” and “The food is very good.” Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 6 The home had a complaints procedure in place and feedback received from residents and / or their representatives confirmed they were aware of who they could talk to if they were not happy and how to complain if a problem arose. One resident stated; “I’m confident Barbara [Manager] or the senior staff would listen and help me if I had a complaint”. Policies and procedures were also in place to ensure an appropriate response to suspicion or evidence of abuse and staff understood their duty of care to protect vulnerable adults from abuse. Staff were available in sufficient numbers to meet the needs of the people living in the home and were observed to spend time socialising and offering appropriate support to residents throughout the day. Systems were in place to review the quality of care provided in the home and to seek residents views on the overall service provided. What has improved since the last inspection? What they could do better:
Some care plans viewed were vague and lacked detail of how the care needs of residents was to be met. Care Plans should be updated to clarify the assessed needs of residents and the level of support required to meet residents’ health, personal and social care needs. Furthermore, the duplication of information in
Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 7 care files should be reviewed as previously recommended, to ensure information in care files is easily accessible. The manager should undertake periodic assessments of the competency of staff responsible for medication, to ensure staff remain fully conversant with the home’s arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. The Complaints Policy should be updated to include details of the Commission for Social Care Inspection as previously recommended, so that people are aware of the contact details of the current regulator. The home’s reference request form should be revised to include a date section for referees to complete. This will help to provide evidence that references are up-to-date and have been completed / received prior to staff being appointed. Arrangements should be made for all new care staff to complete a ‘Skills for Care’ induction, which should be completed within a maximum 12 week period. This will help to provide evidence that staff have been assessed by the manager as ‘Safe to leave.’ 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. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes preadmission assessments and provides residents and / or their relatives with information on the service. This enables people to make an informed choice as to whether the home is able to meet their needs. EVIDENCE: The home’s Annual Quality Assurance Assessment detailed that the home had developed policies and procedures for referral and admission. The manager was able to demonstrate a good understanding of the home’s assessment and admission process. Residents were offered a 4-week trial period and a range of information had been developed to ensure residents were aware of their rights and obligations. The information available included; a copy of the Statement of Purpose, Service User Guide, previous inspection reports, satisfaction questionnaires and information on comments, compliments and complaints. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 10 Feedback received from residents and / or their representatives through discussion and via Care Home Survey forms confirmed the people living in the home had received a Contract and information on the service. Three files were examined during the visit. Two were for residents who had moved into the home since the last visit. Each resident’s file was found to contain a ‘Service User Admission Checklist’, which residents or their representatives had signed, to confirm they were aware of where to find information on the service and returned a copy of the terms and conditions of residency. Files viewed also contained a pre-admission ‘Daily Living and Needs Assessment’ that had been completed by the Registered Manager before each resident had moved in. The assessment document was well constructed and enabled the manager to undertake a detailed assessment of prospective residents’ needs. Assessments viewed had generally been completed to a satisfactory standard. Some gaps were noted for one assessment i.e. the past medical history and medication section had not been completed. The assessment was updated by the manager during the visit. The manager demonstrated a good awareness of equality and diversity issues and the need to consider the diverse needs of prospective residents in order to ensure a holistic assessment was undertaken. The manager was advised to update the home’s assessment documentation to include information on ethnicity and cultural needs as previously recommended. Copies of Assessments completed by social workers had also been obtained for people referred through Care Management arrangements. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents are met by staff who understand the principles of good care practice. EVIDENCE: Three files were examined during the visit. Two were for residents who had moved into the home since the last visit and one was for a resident who had lived in the home for approximately two years. Each file contained an individualised plan of care which outlined the assessed needs, desired outcomes and the level of support required from staff to meet identified needs. Some information was vague and required more detail. Examples were discussed with the manager during the visit. Care Plan agreements had been signed by residents or their representatives to confirm they were in agreement with the information recorded and records confirmed that Care Plans had been kept under monthly review and updated when necessary. There was duplication of some records as noted at the previous inspection.
Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 12 Staff spoken with during the inspection demonstrated a good awareness of the daily living needs of the people living in the home and one resident stated; “Staff understand our needs. They always tell us not to worry and to ask for any help.” Files also contained a range of supporting documentation including; background information, personal profiles, social and life history, family tree, daily routines, likes and dislikes, daily living plans, person centred risk assessments, access to file declaration and medication consent forms, daily report sheets, weight records, functional / dependency assessments, details of personal property, general correspondence / legal paperwork and incident / accident records. Feedback received from residents and their relatives via Care Home Survey forms and discussion confirmed the people living in the home had access to the medical support they needed. Records detailed that residents had attended appointments with chiropodists, general practitioners, optician and district nurses, subject to individual needs. One resident reported; “I think the staff look after our health needs very well.” A health care professional spoken with during the visit stated; “End of life care is also good. Appropriate support is provided to residents and their families.” Previous inspection records confirm that home had a Medication Policy and procedure in place, which included procedures for residents who wished to selfadminister their medication. The manager reported that none of the residents were self-administering medication at the time of the visit. Staff designated with responsibility for the administration of medication reported that they had completed appropriate training and a record of staff responsible for administering medication, together with sample signatures was available. The home used a blister pack system that was dispensed by a local pharmacist. Suitable storage facilities were available for medication and controlled drugs and a resident identification system had been established to ensure safeguards were in place when administering medication. Medication Administration Records viewed were generally maintained to a good standard and the correct codes had been used. In one instance, the balance of medication did not correspond with the written audit trail records and this was discussed with the Owner and Manager. The manager was advised to review the competency of staff responsible for medication, to monitor and ensure best practice. The manager reported that since the last visit she had reviewed each resident’s medication, to ensure medication was administered at the correct times and in accordance with the prescribed instructions. Furthermore, the
Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 13 manager reported that the home had written to General Practitioners to enquire whether they would record the circumstances for administering PRN (as required) medication on individual prescriptions for residents in accordance with best practice. Staff spoken with during the inspection demonstrated a good understanding of the principles of good care practice and the need to ensure residents’ privacy and dignity was respected. Feedback received from residents confirmed that they felt valued by the staff team and received appropriate care and support. Comments included; “I think everyone is very kind to me and they treat me with respect” and “The staff are nice people. They encourage you to do as much as you can for yourself and are there when needed. They are all considerate people.” Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to maintain their independence and exercise choice in relation to daily life, social activities and meals. This enables the people living in the home to lead a lifestyle that satisfies their needs and preferences. EVIDENCE: Thomas House continued to display a monthly programme of activities that was displayed in the home for residents to view. The manager reported that the programme was developed around the recreational needs and preferences of the people living in the home, which were kept under review as part of the care planning process. Details of each resident’s preferences regarding social activities had been recorded in care plans and the home maintained a record of activities provided including the participants. Activities for July included; Church of England and Roman Catholic Communion services; walks in the community to the local park and shops; nail care, pamper and keep fit sessions; hairdressing; board games; birthday celebrations; table top games; newspaper discussions; sing-a-long and film afternoons.
Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 15 Feedback received from residents via discussion and care home survey forms confirmed the majority of residents were satisfied with the range and frequency of activities provided. Comments included; “We have all sorts of activities including keep fit and entertainment”; “There are enough activities for me. It’s easy going and you can choose whether to join in or not” and “I enjoy the sing-a-longs and we always celebrate birthdays.” Residents and relatives spoken with confirmed that visiting times were flexible and that there were no restrictions. Visitors were asked to sign the home’s visitor’s book upon arrival and departure. A relative spoken with said; “I can visit my mum whenever I want.” The routines in the home were observed as being based around the needs and preferences of the people living in the home and this was confirmed in discussion with residents and staff. One resident reported; “I’m pleased with the home. I can’t say anything bad about it. I am free do as I wish within reason.” Likewise, a health care professional reported; “The home provides a very individualised service and the staff are very much aware of each individual’s needs.” The home had a four-week rolling menu. Details of the menu were listed on a large notice board in the dining room and alternative choices were available for each sitting. Meals were served in the home’s dining room although residents could choose to eat in their room if they wished. The dining room was pleasantly decorated and furnished and tables were attractively set with tablecloths, tablemats, napkins and condiments. The home continued to monitor the dietary needs of prospective and current residents as part of the home’s assessment and care planning process. The manager confirmed that special diets would be provided for, subject to individual needs. The inspector discreetly observed residents eating their lunch and teatime meals during visit. Meals were attractively presented and served by care staff who had taken appropriate measures to change their uniform to ensure hygiene standards were maintained. Mealtimes were viewed as a social occasion and appeared relaxed and unhurried. Feedback received from residents confirmed they liked the meals at the home and that additional refreshments were provided during the day. Comments included; “I love the meals”; “I always like something hot for my tea but I love my salads also. I have no problems with lunch time and I like breakfast as I get my bacon on toast that I ask for” and “The food is very good.”
Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are able to express their concerns via a complaints procedure and systems are in place to protect residents from abuse. This protects the rights of residents and ensures an appropriate response to suspicion or evidence of abuse. EVIDENCE: Thomas House had a Complaints Policy in place, which was displayed around the home. The policy outlined the process to follow and timescales involved. The policy had not been updated to include the details of the Commission for Social Care Inspection as previously recommended. The owner advised that she had sent off for labels in order to update the policy with the correct details of the Commission. The Annual Quality Assurance Assessment for the home and Complaints log record detailed that no complaints had been received since the last visit. Feedback from residents via Care Home Survey forms confirmed that residents were aware of who they could talk to if they were not happy and how to complain if a problem arose. Comments from residents included; “I have no complaints. They look after me very well” and “I’m confident Barbara [Manager] or the senior staff would listen and help me if I had a complaint”. Policies and procedures were in place to ensure an appropriate response to suspicion or evidence of abuse. The manager and staff spoken with during the
Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 17 visit demonstrated a good awareness of their duty of care and how to recognise and respond to suspicion or evidence of abuse. Training records showed that all staff had completed training in adult protection. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to benefit from investment and is well maintained and clean. This provides residents with an attractive and comfortable place in which to live. EVIDENCE: At the time of the visit, the home did not have a handyperson. Contractors were hired to maintain the home and grounds as and when required. A programme for routine maintenance and renewal of the home had not been developed as the home received ongoing maintenance and investment as required. The owner reported that since the last visit, the front of the home, kitchen, two bathrooms, two bedrooms and the upstairs and downstairs (back and front corridors) had been redecorated. New quilts had been purchased for all the residents and a new Ozone based washing machine and alarm system had been fitted to the home. The owner continued to undertake monthly health and safety audits, to monitor the condition of the premises and to minimise and control hazards /
Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 19 risks. Systems had also been established for staff to record work in need of attention. All areas viewed during the inspection appeared to be well-maintained and free from hazards. Rooms viewed had been personalised by residents and the fabric and decoration of the home was in good order, providing residents with a pleasant, comfortable and homely place in which to live. Residents were able to meet their family and friends in the privacy of their rooms or in one of the communal areas of the home. Please refer to the ‘Brief Description of the Service’ section for more information on the premises. The home was equipped with a call bell system and a passenger lift and residents had access to personal mobility aids, subject to individual needs. The home’s annual quality assurance assessment detailed that the home had policies and procedures in place for Communicable Diseases, Infection Control and the Control of Substances Hazardous to Health. The home employed two housekeepers and areas viewed were clean and hygienic. The laundry was appropriately equipped to meet the needs of the people living in the home and arrangements had been made to store clean towels outside of the laundry. Overall feedback received from residents via survey forms and through discussion confirmed the home was kept clean, fresh and hygienic. One resident reported; “The home is always kept clean. My niece comments how nice it is too.” Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by appropriate numbers of trained and competent staff. This helps to protect the welfare of the people living in the home. EVIDENCE: The manager reported that no changes had been made to the staffing levels in the home since the last visit. This was verified by examining the rotas and through discussion with staff. Four care staff (including a senior carer) were on duty each day from 8.00 am to 9.00 pm. Two waking night staff were on duty through the night. The manager worked Monday to Friday each week or as required by the service. Feedback received from residents via care home survey forms and discussion confirmed that the care staff were generally available when needed and that the people using the service received the care and support they needed. Comments included; “I am well looked after”; “If I press the buzzer, they come to assist me or deal with my requirements” and “Sometimes you have to wait a short time for something but they never forget you. I’m happy here.” The home’s annual quality assurance assessment detailed that the home had policies and procedures in place for recruitment and employment. Two staff had commenced employment since the last inspection. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 21 Records required under the Care Home Regulations 2001 had been obtained for the new employees. Files contained an application form, a health assessment, Protection of Vulnerable Adult / Criminal Record Bureau certificates and references. The owner and manager were advised to update the home’s reference request form, as the format did not prompt referees to record the date the reference was given. Other supporting documentation including interview records and general employment information was also on files. The home employed seventeen care staff. Records showed that fifteen of the seventeen staff had completed a National Vocational Qualification (NVQ) at level 2 or above in Care (88.23 ). The manager reported that another new member of staff had completed the award and that the home was waiting to view the employee’s certificate. Once the certificate has been received this will bring the total number of qualified staff to 16 (94.12 ). Discussion with staff and examination of training records confirmed that new staff received an in-house induction. The manager and owner were also aware of the new Skills for Care Common Induction Standards. Records showed that the majority of a ‘Skills for Care’ Induction booklet had been completed for only one of the new employees and the Certificate of Completion had not been completed. Advice was given to the Owner and manager regarding timescales, signing off certificates and the need for all new care staff to complete a ‘Skills for Care Induction’. Examination of the home’s training matrix and discussion with staff confirmed staff were supported to access a good range of training courses as part of their employment. Records showed that good progress had been made with Infection Control and Fire training since the last visit and systems were in place to monitor the ongoing training and development needs of staff. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration systems have been developed which enable the home to operate in the best interest of residents. EVIDENCE: The manager of the home (Mrs Barbara Thornber) is registered with the Commission for Social Care Inspection and has approximately 5 years management experience. Feedback received from residents and staff confirmed the manager was approachable and supportive in her management role. Previous inspection records detail that the manager had attained the National Vocational Qualification (NVQ) level 4 Registered Managers Award. The manager reported that she was also in the process of undertaking the National Vocational Qualification in Care at Level 4. Training records viewed confirmed
Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 23 that the manager had also undertaken additional training courses in topics that were relevant to the management of a care home for older people. The owners of the home continued to commission an annual external quality assurance assessment. This was last completed during April 2007. Surveys had also been sent out to residents and / or their relatives during July 2007 and the results of the survey were in the process of being published for people to view. A summary report of the previous survey findings for 2006 was available in the reception area of the home for reference. Monthly reports had been completed in accordance with Regulation 26 of the Care Home Regulations 2001 and discussion with residents and examination of minutes confirmed that three residents meetings had been coordinated since the last inspection. Staff spoken with reported that they participated in staff meetings and received regular formal supervision. The manager reported that she did not act as an appointee for any of the people living in the home. Residents were encouraged to manager their personal finances independently or with support from family members or personal representatives. The home had an accountant who remained responsible for the management of fees and for issuing invoices. Systems were in place to enable residents to pay fees via standing order or cheque / cash on a weekly or monthly basis. The manager reported that she looked after the personal spending money for two residents. The manager demonstrated a good awareness of how to safeguard the financial interests of residents and previous inspection records confirmed that the home maintained written records of transactions and receipts to account for expenditure. The home’s accountant audited financial records and cash balances on a monthly basis. The home’s annual quality assurance assessment detailed that the home had Health and Safety policies and procedures in place and that maintenance and associated records were in place for all key areas with the exception of emergency call equipment. The nurse call system was in the process of being upgraded at the time of the visit. Fire log and service records were checked during the visit. Records confirmed that the fire alarm system and automatic doors were tested on a weekly basis and monthly visual checks of fire fighting equipment and the emergency lighting were also undertaken. A record of staff fire drill training was also maintained. Personal emergency evacuation plans had also been developed for each resident and a fire risk assessment had been developed for the premises. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 24 Since the last visit, the home had made arrangements for the fire alarm system to be serviced. Furthermore, a certificate was on file to confirm the electrical wiring installation had been inspected. An up-to-date service certificate was not available for the fire extinguishers. An invoice was on file to confirm an annual inspection and service of the fire extinguishers had been completed dated 4/05/07. Gas safety and water chlorination certificates / records were also viewed. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 26 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. 1. 2. Refer to Standard OP7 OP7 Good Practice Recommendations Care Plans should be updated, to clarify how the assessed needs of residents are to be met. The manager should audit care plans to remove all duplicated information so that information can be accessed more efficiently. (Repeated recommendation from the previous inspection). The manager should undertake periodic competency assessments for all staff designated with responsibility for recording, handling and administering medication, to ensure best practice. The Complaints policy should be updated to include the details of the Commission for Social Care Inspection. The manager should revise the home’s reference request form, to prompt referees to include the date of references. All new staff should complete a ‘Skills for Care’ Induction within a maximum 12 week period and certificates should be signed off and dated, to confirm staff are ‘Safe to
DS0000022411.V337213.R01.S.doc Version 5.2 Page 27 3. OP9 4. 5. 6. OP16 OP29 OP30 Thomas House Leave’. Thomas House DS0000022411.V337213.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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
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