Inspection on 31/05/05 for Thompson Court

This inspection was carried out on 31st May 2005.

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

Thompson Court 14/09/07

Thompson Court 14/09/06

Thompson Court 01/12/05

Thompson Court 02/02/05

Thompson Court 21/04/04

Similar services:

Snydale Care Home

Abbey The

Whiteley House

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

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 Ann Stoner Unannounced 31 May 2005 10:00am 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. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Thompson Court Address Morton Lane, Crossflatts, Bingley BD16 2EP 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) 01274 561965 01274 563786 City of Bradford Metropolitan Distric Council Dept of Social Services Mrs Miriam Dunn Care Home Only 37 Category(ies) of Old Age (37) Physical Disability (8) Mental registration, with number Disorder (1) of places Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The place for MD is specifically for the named service user. Date of last inspection 2nd February 2005. Brief Description of the Service: Thompson Court is a Local Authority purpose built resource centre, situated in Crossflatts, very close to bus routes and adjacent to the main road to Keighley, Bingley and Skipton. The area surrounding the home is predominantly residential, with a school nearby and within easy walking distance of a railway station. It is a single storey building offering single room accommodation in one of four wings. Two wings offer bed-sitting type rooms, the others have sitting and dining areas. Twenty of the thirty seven bedrooms have en-suite facilities. The home provides personal and residential care for 1 service user who receives permanent care, 8 rehabilitation places, where the stay is usually no longer than 6 weeks, 2 step down places, with priority given to Airedale Hospital discharges, to accommodate people who would otherwise be classified as a delayed discharge in hospital, 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. There are attractive gardens surrounding the home along with a small car park. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year; these may be announced or unannounced visits. The last inspection was unannounced and took place on the 2nd February 2005. There have been no further visits until this unannounced inspection. The people who live in the home use the term service user; therefore this is the term that will be used throughout this report. During the inspection, records were looked at, some areas of the home were seen, such as bedrooms, lounges, dining rooms, laundry, toilets and bathrooms; care staff were seen carrying out their work. Discussions were held during the day with the deputy manager, six members of staff, five visitors and seventeen service users. Comment cards/questionnaires are left for service users, visitors and other professionals at each inspection, thereby giving the opportunity for anonymous feedback. There has been no feedback since the last inspection. A number of requirements and recommendations were made at the last inspection, and an action plan, with timescales, to address these was agreed with the home. The timescale for some of the requirements and recommendations has not expired; therefore these have been carried forward and will be inspected at the next visit. This inspection started at 10.00am and ended at 5.00pm, in addition to the time spent in the home, time was spent preparing for this inspection. What the service does well: The home is clean, very well maintained and decorated and furnished to a high standard. Central courtyards, planted with attractive bedding plants, give level access to outdoor seating areas. Service users and relatives used these areas throughout the day. The layout of the home could mean that service users are isolated on one of the four wings, but this is not the case. The relaxed and informal atmosphere in the home, along with the many social areas, such as the bar and small homely central sitting areas encourages service users to meet up with each other. The home is busy, but staff have time to spend with service users, and visitors. One group of service users, enjoying the sunshine in a courtyard said, “Coming here is like a holiday, you feel free to do whatever you want, there are no regulations.” The degree of flexibility was apparent when two service users booked a taxi and went out for the afternoon. Two other service users said, “We can’t speak highly enough of the home”. This was a view echoed by visitors and also confirmed by the numbers of thank you letters and cards seen in the front entrance of the home. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 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. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 6. Assessment procedures do not guarantee that all the needs of the service user will be met. Service users admitted for rehabilitation are helped to regain their independence and wherever possible return home. EVIDENCE: The care records of a person admitted for his first respite stay were seen. Although an ‘Easy Care’ assessment had been completed, this failed to give the home precise information such as the amount of assistance needed with personal care. The deputy manager said that the home carried out its own assessment on all new service users to the home, but there was no evidence of this taking place for this person. As a consequence, his care plan failed to give details of the precise level of care required. Following a discussion with this service user’s relative it was clear that his recreation and leisure needs had not been accurately identified, resulting in him missing out on a morning activity that he would have enjoyed. A recommendation relating to the above has been made. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 9 Rehabilitation is provided in one wing of the home. There is a kitchen for service users to practice domestic skills, and a treatment room with physiotherapy equipment. The physiotherapists and occupational therapists working on this unit contribute to the service user’s care plan. There is a good level of communication between all members of staff working on this unit. One service user described how she was admitted following major surgery, and with help from the multi-disciplinary team is hoping to return home. She said, “Staff should be proud about the help they have given me. I now feel more confident that I will be able to go home.” Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 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 & 10. Care plans are poor, and although health care needs are met, the lack of appropriate records provides the opportunity for needs to be overlooked. Medication practices have vastly improved, but further work is needed to prevent the risk of potential errors. Service users are treated with respect and their privacy is upheld. EVIDENCE: A good care plan is one that gives precise and detailed information on how and when care is to be delivered, both during the day and at night, paying particular attention to the likes and dislikes of the service user in all aspects of care. The care plans at the home failed to give such detail, for example, information such as ‘wears incontinent pads’ fails to give precise instructions as to the type of pad, and how often it should be changed, requires ‘some assistance with personal care and dressing’, does not give staff instructions about the exact level of care required. One person’s mental health care plan identified a need that was clearly overlooked, the information provided in another person’s mobility care plan was out of date, and there was no reference to the use of commodes in the night care plans of those service users who needed this facility. A risk assessment was seen for a service user Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 11 who wished to have a bath unsupervised. This document was not signed and dated by a staff member, or reviewed on each stay. Evidence was seen in care plans of service users receiving medical treatment from their GP, and one service user described how during her respite stay she had undergone minor eye surgery. She said that following this surgery staff had looked after her well. One person was admitted with a pressure sore, and although this information was available to the home prior to his admission there was no pressure area risk assessment completed or a pressure area care plan in place. Nutritional screening does not routinely take place on admission and falls risk assessments are not always completed. One person who had a falls risk assessment in place was scored as being at low risk of falling, but this had not been reviewed or updated following a number of falls. Medication was seen to be stored securely, and staff described how administration follows guidelines from the Royal Pharmaceutical Society. Because of the transitional service the home provides MAR (Medication Administration Records) have to be handwritten, which unless checked and countersigned by a second person provides the opportunity for potential error. The handwritten charts seen were not countersigned. There is a signed agreement between the home and the service user for those service users who retain and manage their own medication, but service users are not assessed on an individual basis to determine their cognitive ability. Staff were seen to knock on doors before entering, and service users confirmed that this was standard practice. Staff used a shortened version of a service user’s name; this person later confirmed that she preferred this name, and a record to this effect was seen within her care plan. Discussions with staff demonstrated that they have a good understanding of respecting the privacy and dignity of service users. Requirements and recommendations have been made. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 & 15. Service users are offered choices in all aspects of daily living, and their visitors are made to feel welcome. EVIDENCE: Service users described a level of flexibility and choice within the home that included choice of when to go to bed and when to get up in the morning, choice of meals and the opportunity to have a snack between meals. One service user said, “You are free to do what you want. You can help yourself to fruit anytime during the day, have a lie in bed if you want or go for an afternoon nap if you want.” A choice of food is offered at each meal, and service users said that if none of the choices on offer are suitable alternatives are always provided. Evidence of this was seen, as the lunchtime menu was steamed/fried fish, or home made vegetable soup and ham or cheese sandwiches. One person said that he disliked fish, and did not want soup or sandwiches so he was having lamb cutlets. The home has an activity organiser who works between the home and the day centre. Service users spoke highly of the range of activities on offer, and one person explained how at the start of each stay he orders a newspaper, which is delivered each morning. Two service users booked a taxi during the afternoon for an outing. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 13 All of the visitors said that they were made to feel welcome and had access to all parts of the home. A wide range of information is available in the front entrance of the home, for both visitors and service users; this includes information on the ‘Advocacy Service for Older People’, and gives contact details. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18. The level of staff understanding gives assurance that complaints will be taken seriously and service users will be protected from abuse. EVIDENCE: Service users said that they would have no hesitation in making a complaint if the need arose, and staff were very clear on their role when handling a complaint. From discussions with staff it was clear that they have a good understanding of the different forms that abuse may take, and one person had an excellent understanding of the different types of institutional abuse. Senior staff described how they would react to an allegation of abuse and referred to the ‘No Secrets’ guidance. They were confident when explaining how they would deal with an incident occurring out of normal office hours. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 15 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, 20, 21, 22, 23, 24, 25, & 26. The home provides a safe and suitable environment for service users. EVIDENCE: All areas of the home were very clean and tidy with no offensive odours. As a measure of infection control all visitors are asked to use the hand washing gel in the front entrance; some visitors said that they were pleased to see infection control being taken seriously. The home provides a limited service for personal laundry, but this is made aware to service users and their relatives prior to admission. Service users and visitors expressed satisfaction with the standard of accommodation, and service users confirmed that on admission they are offered a key to their room. Specialist equipment such as grab rails, raised toilet seats and tracking hoists are provided. The organisation’s health and safety officer is dealing with recommendations following a recent fire officer’s visit. As a security measure unauthorised access is prevented by an intercom system, and CCTV is in use. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 16 Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 17 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) 30 Staff are trained and competent to do their jobs. EVIDENCE: The deputy manager described the organisation’s system for enabling staff to complete induction and foundation training. This was confirmed by staff who described how they were able to use training materials from the induction and foundation as evidence when being assessed for NVQ (National Vocational Qualifications). Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 18 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) 38 The current system of recording non-reportable accidents is poor, as it provides little information if required at a later stage. Systems are in place to promote the health, safety and welfare of service users, but the availability of cleaning substances poses a potential risk to service users. EVIDENCE: The home uses two systems for the recording of accidents. One system is used for accidents reportable by RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) and another for non-reportable accidents. The recording of non-reportable accidents is very unprofessional. The details are recorded in the first instance in a large book, and are then literally ripped out and placed in individual care plans. As a result of how one record had been ripped from the original book it was impossible to determine the exact information recorded. A monthly analysis is kept, but this does not evidence Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 19 where, when or the time of each accident, therefore making it difficult to identify and developing patterns or trends. Staff confirmed having received training on moving and handling, infection control and food hygiene. The deputy manager said that all senior staff have received first aid training, so that there is a first aider available on each shift. Records of fire bell tests and fire drills were seen. The deputy manager is in the process of developing a training plan to record all mandatory training, which will highlight when updates are required. There is a small kitchen on each wing, which is easily accessible to service users. Cleaning substances such as Cif and Titan Sanitizer were seen on worktops, and washing up liquid had been decanted from a large container into a smaller bottle, but there was no identifying label and no instructions for use. COSHH (Control of Substances Hazardous to Health) risk assessments are in place. Requirements and recommendations have been made. Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 20 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 x x 2 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 3 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 x x x x x 2 Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 21 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 1 Regulation 4,5 Requirement A statement of purpose and service user guide must be provided. This is carried forward from the previous inspection. All service users must be provided with a contract specifying the arrangements made. This is carried forward from the previous inspection. All service users must have a care plan that sets out in detail the action which needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of the service user are met. Service users and/or their representatives should be invited to contribute to the care plan. For service users staying at the home for a period of longer than one month, the care plan must be reviewed at least once a month. For other service users care plans must be updated on Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 22 Timescale for action 30.06.05 2. 2 5,3 30.06.05 3. 7 15 31.08.05 4. 5. 7 8 13(4b) 12 each visit, and must be formally reviewed every third stay. Risk assessments must be reviewed at each stay. Falls risk assessments must be fully implemented. Pressure sore risk assessments must be fully implemented. This is outstanding from a previous inspection. In order to ensure the safe administration of medication all handwritten MAR (Medication Administration Records) must be checked and countersigned by a second person. 31.07.05 31.07.05 6. 9 13(2) 31.07.05 7. 27 18(1a) An assessment must be undertaken on all service users who wish to self medicate. This assessment must take into account their cognitive ability and capacity to manage their own medication. The home must ensure that at all 30.06.05 times persons are working at the home in such numbers as are appropriate for the health and welfare of service users. This is carried forward from the previous inspection. Records of recruitment for all staff must be available in the home. This is carried forward from the previous inspection. Formal documented supervision of care staff must be implemented and take place at the required intervals. This is carried forward from the previous inspection. 8. 29 19 30.06.05 9. 36 18 30.06.05 Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 23 10. 38 13(4a) When not in use cleaning materials must be stored in a secure place. Cleaning substances must not be decanted into other containers. 31.05.05 11. 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 2 Good Practice Recommendations All service users should be provided with a copy of the homes terms and conditions. This is carried forward from the previous inspection. The home should carry out an assessment of need on all service users prior to their initial stay. Nutritional screening should be undertaken on admission. All medication should be verified by the service users GP on or before admission. All accident records should provide a clear and detailed record of how and when the accident happened, the name of any witness to the accident, and the outcome of the accident. If the accident was not witnessed a record should be made of when the person was last seen and by whom. A monthly analysis should take into account where and when accidents occur in order to identify any patterns or trends. 2. 3. 4. 5. 3 8 9 38 Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Aire House Town street Rodley Leeds LS13 1HP 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 Thompson Court v226616 j52 j03 s33518 thompson court v226616 310505 stage 4.doc Version 1.30 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!