Inspection on 05/12/06 for Thorley House

This inspection was carried out on 5th December 2006.

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 05/12/05

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 Mary Corcoran Unannounced Inspection 5th December 2006 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 Thorley House DS0000005765.V304417.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. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 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 Old age, not falling within any other category registration, with number (40), Physical disability over 65 years of age (8) of places Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 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). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 5th December 2005 2. Date of last inspection Brief Description of the Service: Thorley House is a property that was built in the 1950s specifically to accommodate older people and to provide them with residential care. The home has capacity for 40 residents, all of whom have individual bedrooms and has a passenger lift.. 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.V304417.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 6 hours and included a site visit. Part of the time was spent in the office looking at paperwork that must be kept relating to care of the service users, maintenance of the building, staffing levels and training. There was also a tour of the building, and the inspector spoke with three service users, three staff members and one relative. Other staff and service users were spoken with briefly and the inspector observed lunchtime and the daily routine of the home. Six service users and six relatives or friends and one GP returned questionnaires and comments cards; their comments are included in this report. The manager assisted in the inspection. What the service does well: What has improved since the last inspection? Two lounges have been redecorated and have new furniture and carpets, service users were involved in choosing the chairs and the garden has been made more accessible. A new computer has been installed for service users to use, all rooms have digital television and there is a new large flat screen television in the lounge. A quality circle is being set up so that a new project ‘Marvellous Mealtimes’ can be tried out and monitored. A new falls procedure has been put into place which has already had a beneficial effect in decreasing the number of falls in the home. All records are now held on computer so that it is easy to see what changes have happened and what needs to be updated. Care team leaders have undergone training in supervision and appraisals so that more staff have access to regular supervision. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 6 Through training and supervision, and more regular reviews and reassessment of care plans, staff are more person centred and more aware of changing needs. They acknowledge that Thorley House cannot meet the needs of all older people. 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. Thorley House DS0000005765.V304417.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 Thorley House DS0000005765.V304417.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): 1,2,3,5. Quality in this outcome area is good. Prospective service users and their families can be confident that the home will meet their ongoing needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide, called ‘Be yourself’ gives a very good picture of what the home offers and contains a service users’ charter, detailed information of what a service user can expect, clear details about how to complain, the contract and fees. The booklet is in big print and because it is kept on the computer can be made to any size of print. The manager said that any other needs can be met, Braille, different languages and sometimes the manager or care team leader will talk it through with service Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 9 users if this is the best way for people to understand it. One service user said that his daughter got all the information, he visited two homes, this was definitely the one he wanted and ‘they spent two hours looking round and talking with me, finding out what I needed.’ Another person said ‘my daughter got all the information, I looked at three homes, and this was the best.’ Everyone spoken to said they and their families had had a good look round and compared it favourably with other homes. Three service user files were looked at and they all had contracts either through Wigan council who pay the fees or private between the home and the service user. Fees were clearly set out and there were letters informing people of changes in fees. Two service users said that their daughters sorted the contract and fees, one relative said that she had all the information she needed. All the files looked at had detailed assessments which were carried out by the manager or the care team leader before people moved into the home. The assessments were very thorough and were signed by the service user or relative. There was also a copy of a letter to the prospective service user about the assessment and giving assurance that their needs would be met at the home. There is also a ‘life profile’ to be set up for each service user, setting out their likes and dislikes and preferences, as well as important life events and anniversaries. The manager said that knowledge of this helps to identify why people may not be feeling well or ‘seeming down’ if staff can respond appropriately they can help to ‘move people from ill being to well being’. Thorley House DS0000005765.V304417.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, 10, 11. Quality in this outcome area is good Service users feel they are treated with respect and that their personal care and health needs are fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users’ files were well organised and easy to follow, with up to date care plans and a recent photo and emergency details on the front of each file. The care plans are kept in the files and also on the computer so that they are easy to up date and easy for other staff to pick up on any changes. All care plans, which cover all aspects of health and personal well being are audited at least once a year by the manager and reviewed every month by care team leaders who each have a responsibility for a certain number of people. Any changes are noted down. The care plans are signed by the service user or the relative and match the needs identified in the assessments. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 11 All sections of the care plans include a strong reminder about promoting respect and the privacy and dignity of service users, this attitude was observed to be put into practice; staff were respectful and friendly towards service users and people were observed to be asked if they wanted their bedroom doors left open or closed. Staff always knocked and waited for a response before going into rooms and personal care was carried out discreetly. Service users said that they were encouraged to be as independent as possible, one person said ‘I do as much as I can myself but they help when I need it,’ and ‘it is 90 ideal, little hiccups here and there but on the whole the girls are very good.’ A relative said ‘Overall, very satisfied with the care and attention given to my sister by staff.’ At the time of the inspection, the service users looked clean, well groomed and were smartly and appropriately dressed. One relative said ‘staff are very helpful, she (mother) has her own carer who really cares.’ One service user said that the staff know he’s still up at 10pm and always bring him a drink. Risk assessments, including pressure risks are in place and reviewed monthly, one person takes responsibility for his/her own medication which is kept in a locked cupboard in their room. There is a good risk assessment in place, using a flow chart which is reviewed every month. It is recommended that the service user also signs the risk assessment and reviews. The home keeps a record of when residents fall, and has started to use a new system for analysing when and how falls happen, how to improve risk assessments and when to refer to the falls co-ordinator. This has resulted in a decrease in falls, the average number of falls in any month is 10, in October there were 9 and in November there were 3. There is good evidence of working with health providers; district nurses and doctors visit the home, files showed that health assessments had taken place and care needed monitored and recorded. One service user said that the district nurse visits twice a week and the doctor is called when needed. Staff act on requests for example, one service user requested an assessment for a more appropriate wheelchair, this was carried out but when it arrived it was not as the engineer had specified. The service user asked for a reassessment and records show that a request has been sent to the company concerned. It was seen in service users’ files that they had the option to discuss any plans they might want to make for death and dying. People said that they preferred to make the arrangements with their families. The manager has undertaken training in ‘death, bereavement and care of the dying’. The medication system complies with the regulations, all medications are stored in locked cabinets, secured to the wall in a locked room (the clinic) specifically and solely used for medication. Controlled drugs are kept in a further locked cabinet and the fridge temperature is checked and recorded daily. The keys are held by the person who is responsible for medications on Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 12 that day. Full medication training is evidence in staff files for staff who administer medications. The same front sheet and photo of the service user which is on their personal files is on the front of each person’s medication pack, each administration is initialled, there are clear records of medicines received, administered and returned to the pharmacy. As part of a review of the home’s daily routine, extra staff are to be employed early mornings so that senior staff can be released to administer medication on a more flexible and personal basis, which then will give them more time to be involved with people when they get up and at breakfast time. Eventually this will reduce the need for the medicines to be administered from the trolley in the dining room. There was a pharmacy audit of the home’s medication procedure in November 2006 which stated that everything was in good order. The pharmacy then carried out a training session with staff and one service user on the side effects of medications. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 13 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, 15. Quality in this outcome area is excellent Service users have their expectations and preferences met and have choice and control over their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The detailed care plans for each service user set out their needs, preferences and interests. The introduction of Life Profiles will make the care plans more personal and individual. The activities co-ordinator is starting to work with service users and their relatives on compiling the profiles so that staff have a more in depth understanding of each service user’s life experiences and what they want out of life at the home. The library visits every month and there are large print books on the bookshelves in the computer lounge. From looking at service user files, it was noted that religious needs are identified and are met as far as possible. There are regular Church of England and Catholic services at the home and service users are assisted to attend Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 14 church by staff, relatives and volunteers. One service user goes to the Women’s Guild at church every month. The manager said that all service users who wish to are enrolled on ring and ride, and this service is used for people who are going out and about. One person has now gained the confidence to go by taxi herself to the supermarket. There is an activity co-ordinator employed at the home who works a flexible 25 hours a week. The work of the co-ordinator and the staff is evident in the range of activities offered in the home and in the community. There is a calendar of events available and the daily logs of service users show that these have taken place and been enjoyed. Birthdays are celebrated and entertainers are brought in. One service user said that she did not have anything to do but she had her hair done, had a manicure and played bingo. She enjoyed sitting in the foyer watching everyone come and go and was enjoying listening to Christmas carols. The activity co-ordinator also spends time individually with people who prefer this to group activities. One service user said that she played bingo ‘but I don’t make a habit of it.’ One person spoken to has Sky television, own phone and said that ‘between meals, snacks and drinks, there is no time left for anything else!’ At the time of the inspection, service users were having haircuts, sets and perms in a pleasant hairdressing room, by the hairdresser who comes in once or twice a week. Several service users were also getting ready to go out to a pantomime. One staff member said that there are trips out twice a year to Brindley theatre and Rivington Pike. The staff member also said that at weekends, staff teams have responsibilities for arranging activities, in recent weeks these have included a sherry evening, karaoke, bingo, and a sing-along. Recently there has been a clothes party and a Bodyshop party where people could buy new clothes and Christmas presents. There have also been trips out to the Trafford centre and to neighbouring towns for shopping. At the time of the inspection visitors arrived and were made welcome, visitors seemed at home and one relative said she could visit anytime and see her relative in private if she wished, Service users spoken t o said their visitors were welcome anytime and could pop in as often as they wanted. One relative stays for tea twice a week. There is also a private lounge with drinks making facilities where service users can welcome their friends and relatives. Since the last inspection a computer has been installed for the use of service users. This is freely available in a small lounge and staff are happy to assist anyone who wants to use it. One service user used the computer to look up the website for her religion and spent an hour looking at news and photographs. Another person was helped to look up the website of the village where he used to live. Another person has used the computer to follow horse racing. The manager plans to invite a computer company in to give training sessions in using the computer. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 15 There is evidence from the records of residents’ meetings that activities are discussed and put in place and that food and mealtimes are taken very seriously. The home has recently started to use the company’s (CSL) new ‘Marvellous Meals’ system that incorporates MUST (malnutrition universal screening tool). As well as ensuring that people’s nutritional needs are met and monitored, the new system has a code of practice for enhancing the whole mealtime experience. The home is to set up a Quality Circle, a series of small meetings involving staff, service users and relatives to look at how they can put this into practice. The manager says she intends to let people know the outcome of the quality circles in the home’s newsletter and in team and residents’ meetings. At the time of the inspection, lunch was being served in the 2 dining rooms which were bright, homely and had clean, matching tablecloths and serviettes on the tables, with individual ways of people protecting their clothing while they ate. There were teapots, milk and sugar and condiments on each table. There was also a choice of table size and layout. Service users can eat in their rooms if they prefer. There was choice of light lunch, sardines or creamed mushrooms on toast and it was observed that some people were eating a different meal. Cheese and biscuits and grapes served, with second helpings offered. The manager said that there is a five week rolling menu which has a good selection of interesting and nutritional meals, this is confirmed by looking at the menus and talking with service users. Suggestions from residents meetings contribute to the make up of the menus. There are menus on the table at breakfast and service users said that the cook goes round at breakfast, says what’s on for that day and if someone doesn’t want that meal will ask ‘what would you like?’ All service users spoken to said that they could choose what to eat and where and when they liked within reason. Breakfast can last all morning and is buffet style, the manager said and the inspector observed that people linger over breakfast, chat and read the newspapers. Staff said that all diets were catered for, the cook identifies needs and preferences when someone moves into the home and there is a chart in the kitchen so staff know what foods are for which people. All kitchen staff are trained in food hygiene and the two cooks are attending an environmental health training course on nutrition for older people in care homes in December 2006. The home has provided individual pieces of equipment for the kitchen so that a service user’s preferences for meals and the way they are cooked can be catered for. Another service has been offered the opportunity to put kitchen protective clothing on and show the cook how he likes his food prepared. Thorley House DS0000005765.V304417.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, 18. Quality in this outcome area is good Service users can be confident that their complaints will be taken seriously and that they will be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about how to make a complaint is prominently displayed in the reception area as soon as you enter the building. The home’s complaints log is well kept, easy to follow and shows outcomes for complaints. There have been no complaints since the last inspection and none received by CSCI. All service users spoken to said they knew how to complain and who to speak to. One person said ‘I tell them all the time,’ another person said I tell the staff or Rhona (manager),’ and another person said that there was no need to complain ‘I put my case, they put theirs, we accept it, it’s a two way thing, no disputes.’ Complaints procedures are in all service users contracts and personal files and also in the service user guide and statement of purpose. All six service users who returned questionnaires said that they knew how to complain, five people said that staff always listen to them and act on what they’ve said and one person said that this sometimes happens. The six relatives or friends who returned comments cards said that they had no complaints but would know what to do if they had. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 17 Al the service users spoken with felt safe and secure and one relative said ‘. If I have a problem, I only need to speak to staff and they will discuss the matter and find a solution.’ The manager is a qualified trainer and has delivered POVA (protection of vulnerable adults) training to all staff, including casual staff since the last inspection and is planning to provide the training for the hairdresser. The home has a protection of vulnerable adults policy which is followed and staff are showing a much greater understanding of abuse issues. Staff spoken to have a good awareness of forms of abuse and the procedures to follow. A member of staff highlighted an example of cultural and religious misunderstanding that could constitute abuse. The POVA training allowed the particular behaviour to be better understood and strategies will be tried to manage the behaviour as opposed to trying to stop it. This was noted in the service user’s file. Thorley House DS0000005765.V304417.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, 20 21, 24, 25,26. Quality in this outcome area is good Service users live in a clean comfortable environment, which is well maintained and will keep them safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection, the home was seen to be clean, fresh, warm, comfortable and nicely decorated, with well maintained furniture and fittings. The foyer is a favourite place to sit and watch the world go by and there is often competition for chairs. The manager has been looking at options to move the office and enlarge the foyer so that more people can take advantage of it but this depends on budgets and future maintenance plans. Since the last inspection two lounges have been redecorated and have new furniture and carpets, there were new chairs in one of the lounges, chosen by service users. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 19 The garden has been tidied and made more accessible. The manager and service users say it is well used in good weather. The inspector observed the cleaning round and the thoroughness of the cleaning process. There are store rooms on the both the ground floor and first floor for storing wheelchairs and moving and handling equipment. Frequently used portable hoists are stored safely out of the way in an alcove for speedy access. There is a maintenance plan in place, the entrance hall and adjoining hall carpet, although not an immediate hazard is worn and is to be replaced in the near future. There are sufficient bathroom and toilet facilities to meet the needs of the service users, all were very clean and contained liquid soap and paper towels with no evidence of people using communal toiletries. Five service users in their questionnaires say that the home is always clean, one person says it usually is, one person added ‘ the home is very clean and the roast potatoes are good.’ Relatives and friends all said the home was clean and comments included ‘The home is immaculate’ and ‘Spotless clean. Mum is very happy here, makes me happy too.’ It is recommended that the bathroom windowsill in a downstairs bathroom is renewed or repainted, where toiletries being placed on it have rubbed off the paint. One ensuite bedroom that was looked at was clean and had room to manoeuvre safely. All the bedrooms that were looked at were clean, safe and individually personalised with photos, pictures, lamps, and a variety of personal possessions. The bedrooms can be redecorated when people move into the home or on request at any time. One resident told me that her daughter had been in and repainted her room for her. Another service user said that he could have anything he wanted in his room ‘phone, Sky television, anything I want.’ There is a private lounge with drinks making facilities where service users can meet their friends and relatives. The home has a mini com system, with a loop system in the computer lounge, the blue lounge and the dining room to promote communication and inclusion for people who are deaf. There is a separate staff room with lockers and a cold drinks machine. As mentioned previously, the home keeps a record of when residents fall. And has started to use a new system for analysing when and how falls happen, how to improve risk assessments of the environment and when to refer to the falls co-ordinator. This has resulted in a decrease in falls, the average number of falls in any month was10, in October this year there were 9 and in November there were 3. There is a maintenance plan in place and all fire alarms, drills, and equipment checks are recorded and up to date. All staff have signed the fire procedure and the home complies with all health and safety requirements including the Greater Manchester Fire and Rescue Service precautions check in February 2006. An improvement since the last inspection is a full fire risk assessment Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 20 carried out by an external consultant annually. The first assessment found some improvements were needed and showed photographs of the hazards. The manager said that this has more impact than just a written report and the hazards have now been removed or attended to. Staff have a list of their responsibilities for carrying out health and safety audits in service users’ bedrooms. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 21 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, 30. Quality in this outcome area is good Service users’ needs are met by the numbers and skill mix of staff and are protected by the homes policies and procedures regarding competent staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From looking at the staff rotas, talking with staff, service users and the manager, it is seen that there are always two members of staff on duty at night, from 9.45pm to 7.45 am, one of who is a senior. During the day, there are a minimum of three care staff (often four in the mornings) plus a senior or a care team leader on duty. The manager is supernumerary, which means she has time to oversee the home and carry out managerial duties. This staffing level meets the minimum standards for a care home of this size and level of dependency. The manager has recruited extra staff to work from 7am so that the senior staff can be more flexible with the morning medication routine and be more involved with service users at breakfast time. There is sufficient domestic and kitchen staff and two cooks but the manager is hoping recruit an extra cook for evenings so that the evening meal can be more flexible. There is an activity co-ordinator employed for 25 hours a week and a maintenance person employed for 19.5 hours a week. The manager is on call out of office hours. Thorley House is part of a bigger Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 22 organisation, CSL, and there is provision for on call from one of the sister homes. One staff member spoken with said that it would be beneficial to have an extra member of staff on duty, including nights, another staff member said that extra staff would help but she did not feel ‘pressured or rushed, we can cope.’ The rotas are well organised and leave time for a handover between shifts. Service users who returned questionnaires said that ‘there should be more carers on duty with a better wage,’ and ‘I think staff are run off their feet and do not have a lot of time.’ Another person said ‘I don’t ask for much help but when I do I get it. They can’t always be there immediately but pretty pronto.’ At the time of the inspection staff were available to assist people and did so speedily and in a respectful, cheerful manner. Relatives who returned comments cards said that ‘there never seem to be enough staff and over the past few months the number of people who have been taken on seem to me, to need a lot of care. I have no complaints about the staff, they do their best and are always pleasant.’ Another person said ‘you could do with a cordless phone so your staff can carry it with them, because when you ring you could be waiting a long time before the phone is answered.’ The manager said that a situation arose in the summer where the needs of several people changed. After reassessment, it was decided that Thorley House could not meet their extra needs and they transferred to a more appropriate home where their health and well being could be assured. The situation had an effect on staff time and responsiveness but this has now been resolved. Three staff files were looked at and show that staff have regular one to one supervision and an annual appraisal. The manager has used direct observation as a supervision aid, this was confirmed by looking at the files. The appraisal includes a self assessment and identifies any training needs that staff have in order to be able to do their work. The learning objectives are monitored in supervision meetings. The manager keeps a record of all staff and their training on the computer so that she can keep track of the training they’ve had, the training they need and when ‘refresher’ or update training is due. Staff spoken to confirm that this happens and were clear about the training they had had and what was due. The manager said that casual staff are included in training and that she has plans to include the hairdresser in first aid and POVA training. All staff are well supervised and have had the required training ensuring that they are competent in their jobs. There is a list of staff, their qualifications and experience in the service users guide which could give confidence to service users about the competence of the staff team. The home’s recruitment policy and procedure is followed to ensure that the right people are recruited for the job. The staff files show that they are all CRB (criminal records bureau) checked, have 2 written references and have undergone an induction to the work before they work on their own. One staff Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 23 member said that her induction lasted six weeks. The manager is to start using the new Skills for Care induction package with all new staff. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 24 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, 32, 33, 35, 36, 38. Quality in this outcome area is good Service users live in a well run, well managed home with their health, well being and safety promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has 25 years experience of working in care homes for older people and has been the manager at Thorley House since 2003. She holds the Registered Managers Award, NVQ level 4 in care, is an NVQ assessor and is qualified to train. These details are included in the service users suide. The company works with the manager in researching new legislation and methods and she constantly strives to improve the service. This is evident from the Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 25 ‘marvellous mealtimes’ project, the new falls monitoring procedure, implementing the new induction process and the installation of the residents’ computer. Because the manager’s working hours are not included in care duties, she is able to oversee the home, supervise the staff and carry out her managerial duties with support from the home services manager. The manager is evidently in touch with everything going on in the home, through observation she knew everyone by name, could discuss their needs and preferences and was therefore able to see that their needs were being met. Staff were seen to be comfortable approaching he, and her attitude and sensitivity has a positive effect on the staff, service users and atmosphere of the home. One member of staff said that the manager ‘always has the same attitude, never seen her in a bad mood, never sharp, always has time for everybody.’ Service users, relatives and other professionals and agencies are asked to complete a survey every year. The manager collates the responses and produces a business plan which includes the views of the people who have replied. Care plans are reviewed monthly or more frequently if necessary to make sure that people needs are still being met. Residents meetings are minuted and show that their views are listened to and action taken as far as possible. As mentioned previously, a quality circle is to be set up where service users will be involved in deciding how the mealtimes improvement can be carried forward. Service users’ personal money is kept in a locked safe, the keys being held by the manager and the home services manager who showed me the method of safekeeping. Each service user has a clear, labelled plastic wallet, kept together in a tin in the safe. The inspector looked at the records which show money coming in and money going out correctly. The company audits the finances and there are clear policies and procedures in place. All health and safety checks are in place, protective clothing is provided, clinical waste is disposed of correctly and staff training is up to date. It was noted that CSCI was not notified of a specific incident, the manager must ensure that all possibly harmful incidents are entered on a regulation 37 report and sent to CSCI. Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 26 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 4 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 x x 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 x 3 3 x 3 Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 27 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 OP9 Good Practice Recommendations The service user who is responsible for his/her medication should agree to and sign the risk assessment and reviews. The windowsill in a ground floor bathroom should be repainted or replaced with a surface resistant to toiletries . OP23 Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Thorley House DS0000005765.V304417.R01.S.doc Version 5.2 Page 29 - 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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