Inspection on 05/12/05 for Thorley House

This inspection was carried out on 5th December 2005.

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

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

Other inspections for this house

Thorley House 29/01/09

Thorley House 05/12/06

Thorley House 23/08/05

Thorley House 22/12/04

Thorley House 02/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Thorley House Hazelmere Gardens Hindley Wigan Greater Manchester WN2 3QD Lead Inspector Lindsey Withers Unannounced Inspection 5th December 2005 09:25 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 Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 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. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thorley House Address Hazelmere Gardens Hindley Wigan Greater Manchester WN2 3QD 01942 255370 01942 525054 rhona.briggs@clsgroup,org,uk www.clsgroup.org.uk CLS Care Services Limited 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) Mrs Rhona Briggs Care Home 40 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (8) Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: up to 40 service users in the category of OP (Older People over 65 years of age) to include: 8 service users in the category of PD(E) (Physical Disability over 65 years of age). 1 female service user in the category of DE(E) Dementia over 65 years of age. One named service user (TM) may be accommodated in the category of DE(E) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 22nd December 2004 2. 3. Date of last inspection Brief Description of the Service: Thorley House is a property that was built in the 1950s specifically to accommodate elderly people and to provide them with residential care. The home has capacity for 40 residents, all of whom have individual bedrooms. The home is situated between large council housing estates and privately owned properties, and many residents move here from the local community. It is served by a good bus route and is close to local shops. Parking is available for visitors. Thorley House is part of the CLS group of homes. CLS has several homes in the Wigan and Leigh area. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over 3 hours on one day, and was unannounced. Part of the time was spent in the office looking at the paperwork that the home needs to keep that relate to the care provided to residents. Bathrooms were checked to make sure there were no communal toiletries being used. The Inspector spoke with two members of staff, and had good conversations with three residents. Other residents and staff were briefly spoken to during the course of the inspection. In the absence of the Manager (on holiday), the Care Team Leader on duty was in charge of the home and assisted the Inspector during her visit. The Pharmacy Inspector had visited the home on 30th September 2005 and had written separately with her requirements (3) and recommendations (3). A copy of her letter can be made available to members of the public or other enquirers on application to the CSCI. What the service does well: What has improved since the last inspection? The carpet in the main dining room has been cleaned and is now being deep cleaned on a monthly basis. The carpet in the small dining room has been cleaned and stretched so it no longer poses a trip hazard to residents. It, too, is being deep cleaned on a monthly basis. All toiletries have been removed from the bathrooms and are returned to residents’ rooms after bathing. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 6 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. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 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 Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 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 the following standard(s): 3 and 4 Pre-admission assessments were good and formed the basis of the residents plan of care, ensuring needs were identified and met. Staff working at Thorley House are properly trained and have a wide range of skills. Residents can be assured, therefore, that their needs can be met. EVIDENCE: Three care plans were looked at. It was clear from the written records that a full assessment had been undertaken prior to the resident moving into Thorley House. There was evidence to confirm that social workers and other supporters had been involved in the assessment and admission process. One resident had recently moved into the home from hospital. She said that she had found the transition difficult, particularly giving up her own home of more than 70 years. However, she said staff at the home had been very good, helping her to adjust and explaining explained what care they could provide to her. The resident had expressed some personal preferences and she said that these had been taken into consideration. She said she felt confident that staff at the home would make sure she improved in health. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7, 8, and 10. Standard 9 was assessed separately on 30th September 2005. The standard of care planning and review is good and provides staff with the information they needed to meet the residents needs. The health needs of residents are being met, in collaboration with other agencies, as needed. Staff work hard to ensure that residents were treated with dignity and that their right to privacy and respect is maintained. EVIDENCE: Three care plans were looked at including the record for one person who had recently moved into the home. Thorley House staff have chosen to produce care plans on computer in a large font. This makes them very easy to read, particularly for a resident who might have a visual impairment. Each record set out in detail the aspects of health, personal and social care needs of the resident, and showed that amendments had been made when necessary, but at least once per month. The Care Team Leaders each have a number of care plans for which they are responsible. They maintain a chart in the Care Team Leaders’ office so that they do not miss any monthly reviews. There was evidence on two of the three files to show that the Manager has audited the care plans. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 10 The content of care plans had been based on the initial assessment. Risk assessments had been written for each person. Some risk assessments applied to all residents, for example, in relation to the prevention of falls, while others were specific to the individual, for example, in relation to choice of footwear. All risk assessments had been reviewed at least once per month and had been adjusted, where appropriate. Entries were clearly written, and all those care plans seen at this inspection had been signed by the resident or their representative. The documents clearly demonstrated that residents had been involved in developing the plan of care. Two minor anomalies were identified in the care plans: staff should take care to ensure new entries are dated; staff should take care to make sure information in the progress sheet is cross-checked to the appropriate section of the care plan. Both these matters were discussed with the Care Team Leader at the time of the inspection. One resident spoke about her personal carer, with whom she said she had a good relationship. The resident said this person was responsible for making sure she had everything she needed. Care plans showed the different techniques that had been employed to encourage a resident to maintain independence, and that help was provided, if needed. Residents spoke about the support they had to assist them with personal care. All three residents spoken to on this occasion were largely selfcaring and enjoyed the fact that they were encouraged and supported to remain so. The records showed that residents had been assessed by an appropriate health professional where there were concerns, for example, regarding pressure areas, continence, or diet and nutrition. There was evidence in the records of staff chasing up results, for example, of tests, or outstanding consultancy appointments. Staff have a good system for making sure residents keep their hospital or other appointments. One resident said that the system worked well and if a member of the family could not take her to an appointment, the home arranged for a member of staff to accompany her. Residents spoke about having seen the hospital specialist, the District Nurse, and the GP. In general, those residents spoken to appeared to have a good insight into their physical condition and any treatment that they were receiving. The Inspector observed the Care Team Leader’s persistence in trying to contact the GP surgery on behalf of a resident. The new CLS care planning documentation was slowly being introduced. Staff had received training. Where staff had identified shortfalls in the paperwork, they had introduced separate Thorley House forms, for example, in relation to the reviews of risk assessments. Records emphasised the need for a residents privacy and dignity to be maintained at all times. The records frequently referred to residents giving Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 11 consent or agreement. Residents said that they were not made to feel embarrassed about personal care and if they wished to do something themselves, they were supported to do so. Staff were heard to be speaking kindly to residents, enjoying social conversation in a respectful way. Staff were friendly – though not overly so. They spoke to residents in a way that did not patronise or demean them. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14, and 15. Residents can expect to experience a lifestyle that suits their expectations and preferences. Visitors to the home are made welcome; contact with family and friends is encouraged. Residents can exercise choice and control over their lives and can expect to be served food that is wholesome, nourishing, and suited to their taste. EVIDENCE: The records showed that residents are offered a range of activities and social events both inside and outside of the home. Indoors, activities might include bingo, dominoes, listening to music, or reading books, magazines and daily newspapers. Excursions are arranged to places that residents have expressed a wish to visit. A small number of residents might go out for a pub lunch or to visit another CLS home when they are having a show or a party. Residents had very much enjoyed the visits from children from a local school and brownies pack who had come to sing Christmas songs. One resident said that, because she was “not as good as I was”, rather than her not go out with her family, staff had “sorted things out” so she could. She now had the loan of a wheelchair for use when she went out. The resident had been pleased to be able to maintain this aspect of her life which she said was “very important” to her. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 13 “Resident choice” is very much the focus and staff were seen to be working with this in mind. During the course of their work, a member of staff was heard to ask residents what they would like to be doing: listening to music? Radio or CD? Residents chose to listen to Hot Chocolate – evoking memories of her daughter’s youth for one resident - and then later, music from the 1940s. This suggests that residents are viewed as individuals and not as “older people”. Those residents who preferred to spend some time in their room were free to do so, and staff were seen to be popping in to make sure residents were all right. Thorley House residents are fortunate in that they receive lots of visitors. A good number called to the home during the time of the inspection. All were made welcome. Relationships between visitors and staff appeared good. Staff appeared familiar with the routines of residents’ visitors so they knew when a resident might be going out or receiving friends or family. Residents are able to visit local churches (either with a member of staff or with families), and members of the clergy visit the home. Residents regarded the quality of food served to them very highly. Breakfast time is particularly popular. Residents enjoy a wide variety of breakfast foods and some like to linger over extra cups of tea. One resident said that she knew staff were looking after her and making sure she had enough nourishment. She said she knew this because that morning, staff had suggested she might have an egg with her breakfast. Another resident said that staff make sure she’s eaten enough. A member of staff took the orders from residents for the lunch- and tea-time meals. Lunch was Scotch broth soup, ham and chips, bread and butter, and mince slice. Some residents asked questions about the food, and the member of staff provided explanations. Choices were offered: corned beef or chicken drumstick rather than ham. One resident said she was “spoilt for choice”. Another was happy with the first choice: “That’ll do for me!” The tea-time option of mince, vegetables and new potatoes would, residents said, be “very good”. One resident said she liked her food “sloppy” to make it easy to eat, and this was what she got. Care plans recorded where residents needed assistance with eating, for example, with the aid of large handled cutlery, or where a resident might need a little encouragement. In conversation with the Care Team Leader, it was clear that staff see good nutrition as central to good health. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: This section was not assessed on this occasion. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 Residents can be assured that they will live in a clean home that is wellmaintained and where they will be kept safe. EVIDENCE: Since the last inspection, the carpets in the two ground floor dining rooms have been cleaned. A monthly cleaning programme has been arranged. The carpet in the smaller dining room has been stretched to make it fit better, so removing the trip hazard. The Care Team Leader (the person in charge on the day of this inspection) said that they were waiting the budget for the coming year to see what funds would be available for redecoration and refurbishment. She said that they hoped to repaint bathrooms and to recarpet the small dining-room. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: This section was not assessed on this occasion. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 Residents and staff can feel certain that their health, safety and welfare will be promoted and protected. EVIDENCE: Since the last inspection, all personal toiletries have been removed from bathrooms. Staff are aware they must assist residents to return toiletries to bedrooms following bathing. Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 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 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Thorley House DS0000005765.V269880.R01.S.doc Version 5.0 Page 19 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 Refer to Standard OP7 Good Practice Recommendations Staff should take care when making entries in care plans so that they are dated, and that information is crosschecked from the progress sheet to the main care plan. 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