Inspection on 14/09/07 for Thompson Court

This inspection was carried out on 14th September 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Thompson Court 14/09/06

Thompson Court 01/12/05

Thompson Court 31/05/05

Thompson Court 02/02/05

Thompson Court 21/04/04

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

CARE HOMES FOR OLDER PEOPLE Thompson Court Morton Lane Crossflatts Bingley BD16 2EP Lead Inspector Pamela Cunningham Key Unannounced Inspection 14th September 2007 09:45 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 Thompson Court DS0000033518.V346718.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. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thompson Court Address Morton Lane Crossflatts Bingley BD16 2EP 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) 01274 561965 01274 563786 City of Bradford Metropolitan District Council Department of Social Services Mrs Miriam Dunn Care Home 37 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (37), Physical disability (8) Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for MD is specifically for the named service user. Date of last inspection 14th September 2006 Brief Description of the Service: Thompson Court is a Bradford Local Authority purpose built resource centre, situated in the Crossflatts area, very close to bus routes and adjacent to the main road to Keighley, Bingley and Skipton. The area surrounding the home is predominantly residential, within easy walking distance of a railway station. The home has a small car park and there is parking on the roadside. Thompson Court is a single storey building offering single room accommodation in one of four wings. Two wings offer bed-sitting rooms; the others have shared lounge and dining areas. Twenty of the thirty-seven bedrooms have en-suite facilities. There are attractive gardens surrounding the home. The home provides personal and residential care for 1 service user who receives permanent care. There are 8 rehabilitation places, where the stay is usually no longer than 6 weeks. The home has 2 ‘step down’ places, with priority given to Airedale Hospital discharges, to accommodate people who would otherwise have to stay in hospital for longer. There are 2 social assessment places, to reduce the need for crisis intervention at home, and 24 places for respite, rotational and short stay care. There is also a day centre with twenty places available from Monday to Friday. Day care services are not regulated. The fees vary depending upon the payment conditions of whichever service the person is using. There is no fee for people referred for rehabilitation under the intermediate care regulations. The full fee for one week’s respite stay is £435.68, but the amount paid depends upon the person’s individual circumstances. Hairdressing, chiropody and newspapers are charged individually. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One visit was made on 14 September 2007. The home did not know that this was going to happen. Feedback was given to the manager and deputy manager during and at the end of the visit. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents. Before visiting the home the inspector asked for information from the manager (The AQAA – Annual Quality Assurance Assessment) which asks about what policies and procedures are in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Comment cards were sent to the home to be given to residents, their relatives and other visitors to find out what their views of the home were. The views of doctors and district nurses who visit the home were also asked for. At the time of writing this report seven resident, four relatives and three doctor’s responses had been returned. In order to find out how well staff knew residents, care plans were looked at during the visit and residents, visitors and staff were spoken to. Other records in the home were looked at such as staff files, training records and complaints received. What the service does well: Information about services provided by the home is available and lets residents and their relatives decide if the home will be suitable for them. They can make trial visits to the home if they want to. The home does well to provide a good quality service and safe medication control system to the diverse types of clients they care for. Communication in the home is good, and the staff provide a homely relaxed atmosphere. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have enough information about the home to decide if it will meet their needs. EVIDENCE: Information for relatives and visitors in the form of the a Statement of Purpose and function and Service User Guide were on view in the home alongside a copy of the last Inspection Report, the complaint procedure and advocacy information. The Service User Guide can be supplied in large print. Residents and visitors said that they received enough information about the home when they came to look round and they were offered a trial visit. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 9 Before a resident comes to live at the home a pre admission assessment is carried out to make sure that the home will be suitable for them. Two were looked at which identified their needs. Information from the doctor’s surveys and other health care professionals involved in the residents care said that staff made appropriate decisions when they could no longer meet an individual residents care needs. There is still no contract of residency in place for those people receiving short/respite stay. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 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. 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. Resident’s health and personal care needs are met and their privacy is respected. EVIDENCE: There are no permanent residents living at Thompson Court. The people presently receiving a service in the home are a selection of Social Assessment, Rehabilitation or Rotational Care, and short stay. I looked at care plan documentation of four residents. One receiving rehabilitation. One for Social Assessment. One for Rotational Care, and one for short stay. I was told the only people admitted for care who were not assessed before admission were the people receiving rehabilitation, and that the physiotherapists assessed the care needs of these people. . These are Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 11 reviewed on a weekly basis by the multidisciplinary team. This was confirmed by speaking to the physiotherapist present at the home on the day of the visit. Pre admission assessments seen were very informative and care plans written clearly identified the care needs of the individual, were person centred gave clear instructions on how the care was to be delivered, and contained evidence of either resident or relative involvement in the process. Activity care plans were also in place. All risk assessment were in place where a risk had been identified, and a care plan was in place where any person receiving a service had been assessed as being at risk from developing pressure sores. These people had an appropriate piece of pressure relieving equipment in place on the bed and in the chair they sat I when not in bed. The home has its own supply of this specialist equipment, and where a different piece of equipment had been identified as needed, this is supplied. Night care plans were also in place and were very informative. As previously stated, although the care plans were very good, they were very bulky and not easy to use. The home needs a simple assessment and care plan format for those service users admitted for short stay, who may not need any further care admissions. A sample assessment and care plane was sent to the manager following the inspection. There was a ‘daily occurrence record’ present for each service user. These could be improved and provide more detail of the daily care given, as currently they contained bland statement such as ‘appeared fine’, and ‘appeared well’. One daily occurrence record of a lady admitted on 11/09/07 just said ‘admitted this evening, appears well, no complaints’. This gives the care staff no information about the lady, or of any immediate needs she might have. The medication system in use in the home is very diverse. It is also very well managed and safe. The system in use is whatever the resident brings in with them on the day they are admitted. The medication policy is a Core Social Services Policy amended and adapted for specific services. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Resident’s lifestyle in the home matches their expectations and they are helped to exercise choice and control over their lives. EVIDENCE: Residents are helped to make choices about how and where they spend their time. On the day of the visit it was made it was clear that some liked to spend time in their own rooms, while some said they liked to visit the day centre. Otherwise they said they could watch what they wanted on their televisions, listen to radio programmes or music or just sit quietly reading. Those who chose to spend the day in their rooms said that staff would ask regularly if they wanted to go to the communal areas and it was up to them if they had their meals in their own rooms, the dining room or one of the lounges. Links have been made with local churches and monthly communion services are held for those who want to receive it. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 13 There is an activities coordinator who works five out of seven days each week, and who makes sure all residents have an activities care plan.. The staff also were contribute to help provide the planned festive activities. Information from talking to residents and survey forms returned showed That: * Activities were arranged by the home and they could choose whether or not to join in. * Their visitors could come at any time and were always welcomed into the home and offered refreshments. * They enjoyed the meals provided and some commented that the food was very good. One said that they had gained 2 kilograms in weight since they had been coming to visit the home. The menus are varied, and seem to take in to account the dietary needs of the residents. There are choices available at all meal times and alternatives are offered if they do not want what is on the menu. The kitchens were clean, tidy and well organised. Records of cleaning schedules, food delivery and serving temperatures and fridge temperatures are kept. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Residents and their relatives can be confident that any concerns they might have will be listened to, taken seriously and acted upon. EVIDENCE: There has been one complaint made to the home since the last inspection. This was made by a senior care manager on behalf of a resident who was unhappy with the care they received. and involved the Adult Protection Unit. Documents from this complaint were seen. The complaint was appropriately managed. Copies of the organisations adult protection procedures and the local authority adult protection procedures are kept in the manager’s office. All staff have received training around abuse and adult protection over the last six months. The manager has also done the local authority two day managers course about adult protection. The home has an appropriate complaint procedure that is clear and easy to follow. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 15 Speaking to residents during the inspection, and from comment cards received, it was clear they and their relatives knew how to make a complaint and who to complaint to if they had any concerns. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 16 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, 20, 21, 22, 23, 24, 25, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable, clean and well-maintained home that is suitable for their needs. EVIDENCE: I looked around the home, as this was my first visit to the building. The thirty-seven bedrooms are all single rooms; twenty have en suite facilities. Some of the rooms have ceiling mounted track hoists fitted. On the rehabilitation wing the tracking in one bedroom goes straight through to one of the main the bathrooms. When that service user is not using the bathroom the connecting doors are locked. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 17 There are adequate handrails along the corridors and grab rails in the bathrooms and toilets, to assist those resident who are not very mobile. Some toilets have raised seats fitted. The doors are wide and the shared parts of the home are spacious. Some of the bedrooms are larger than others and are usually offered to people who need additional space. The bedrooms are well furnished, and some delightfully personalised. There are appropriate locks to the doors. Inside each room are a lockable storage drawer and medicine cabinet. The laundry is light and spacious and has all the equipment needed. There is a sluice programme on each washing machine. The floor is tiled and the walls can be easily cleaned. Soiled linen is kept separately from clean linen and the home has an adequate infection control policy and procedure in place. The bedrooms are well furnished and the doors have locks. Inside each room are a lockable storage drawer and medicine cabinet. Service users are welcome to bring personal items with them to make their room more homely. The whole house is clean and hygienically maintained. On the questionnaires, people confirmed that the home is kept fresh and clean, and does not smell. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 18 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. EVIDENCE: Two weeks duty rotas were seen during the visit. These showed that there were enough staff on duty to meet the needs of residents. Information from residents and their relatives confirmed this. There are however some vacancies in the home, and on two nights per week there are only two waking night staff on duty. Two waking night staff would find it difficult to meet the needs of the service users when the home was full to capacity, as the building is spread over a large area. Other vacancies identified during the visit are as follows. 2, x 16 hours domestic staff. 2 x 20 hour senior night carers, and 1 x 20 hour night carer. There is also a shortfall of 105 hours in the day centre, which must no be supplemented by the care staff from the care home. I was told by the deputy manager that all mandatory training was being addressed, and that formal supervision was in place, however without the presence of a training Matrix this was difficult to confirm other than speaking to all staff employed and by locking at each individual training record. She said she was currently in the process of developing a training Matrix. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 19 I was told that the deputy manager has an NVQ level 4, that the manager has a recognised social work certificate (CSS), has the NVQ level 4 and is currently in the process of completing the Registered Managers Award. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 20 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. The home is managed and run in the best interests of residents. EVIDENCE: The manager has been employed in a managerial position in the home for many years and is fully able to discharge her duties as Registered Manager competently. She is a qualified social worker, has successfully completed her NVQ level 4, and is currently completing the Registered Manager s Award. She has also has successfully completed the registration process with the CSCI. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 21 On speaking to the staff it is quite evident the manager is popular with them, and has knowledge of individual residents. Staff spoken to also said she was very approachable. There are clear lines of responsibility in the home, and the manager said senior officers are identified to be in charge of the home on a rota basis when she is on annual, leave. The manager said she operates an open door policy and is accessible to residents, relative and staff. Information from relatives spoken to say that they thought the home was well managed and run. Staff meetings are held every regularly to discuss any issues, training and to introduce new staff to the team. Individual wing meetings are also held to discuss matters relating to individual residents. Full staff meetings are held periodically, and meetings with the domestic staff are held twice a year. Supervision records were seen in staff files seen, and staff said they found the sessions helpful. One member of staff said she was encouraged to read the care documentation by the manager and that helped her to get to know the residents she is key worker for. The manager said twice yearly appraisals also take place. This is also identified in the AQAA. The manager said quality assurance surveys are done on an annual basis and the information audited by the BMDC. Individual records and home records are secure, up to date and in good order in accordance with the Data Protection Act 1998. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 22 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 2 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 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes 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 OP2 Regulation 5 (3) Requirement The registered provider must ensure all service users are provided with a contract specifying the arrangements made for their stay. This is outstanding from 2/02/05, 31/05/05 and 1/12/05. 31/12/07 and must now be addressed. The registered provider must ensure that there are sufficient staff in the building particularly on waking night duty to provide for the needs of the residents, and also to make sure the residents are not placed at risk in any way. In the event of a fire in the building. Timescale for action 31/12/07 2 OP27 15 31/12/07 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 Good Practice Recommendations DS0000033518.V346718.R01.S.doc Version 5.2 Page 24 Thompson Court 1. Standard OP31 The home’s manager should complete the Registered Managers’ Award in order to meet this standard. Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI Thompson Court DS0000033518.V346718.R01.S.doc Version 5.2 Page 26 - 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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