Inspection on 26/02/07 for Thornbury Care Centre

This inspection was carried out on 26th February 2007.

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

Other inspections for this house

Thornbury Care Centre 28/05/09

Thornbury Care Centre 09/11/07

Thornbury Care Centre 15/08/06

Thornbury Care Centre 30/11/05

Thornbury Care Centre 28/06/05

Thornbury Care Centre 23/03/05

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Thornbury Care Centre 58 Thorndale Road Thorney Close Sunderland SR3 4JG Lead Inspector Miss Nic Shaw Unannounced Inspection 10:00 26 & 27 February 2007 th th 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 Thornbury Care Centre DS0000063778.V330267.R02.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. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornbury Care Centre Address 58 Thorndale Road Thorney Close Sunderland SR3 4JG 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) 0191 5201881 www.europeancare.co.uk European Care (England) Ltd Debra Mary Fairless Care Home 44 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (23), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (6), Old age, not falling within any other category (21), Physical disability (2), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (6) Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2006 Brief Description of the Service: Thornbury Care Centre is a three story building situated in the centre of Thorney Close. The home is registered for up to 44 people, 23 of whom have a dementia type illness. Nursing care is not provided but district nursing services can be used as required. The home is built on a sloping sight with accommodation for service users over two floors with a service area on the lower ground floor. Accommodation consists of a lounge and dining room and bathroom on each floor. A passenger lift serves the first floor, which specifically provides accommodation for people with dementia care needs. All bedrooms are single occupancy and each benefits from en-suite shower and toilet facilities. The home has been specifically designed to provide accommodation for people who have a physical disability. There is a spacious garden to the rear of the home and a car parking facility is provided adjacent to the home. The home is situated close to local shops, pubs, places of worship and a community centre. The weekly fees payable are £346-£425. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This second key unannounced inspection was carried out over two days in February 2007. The inspection included talking to service users, relatives and staff. The registered manager was not available, however, the deputy manager was able to offer assistance with the inspection. In order to find out what it was like for people with dementia living at the home, time was spent observing staff and their interactions with them, and this included observing a meal. Time was spent looking around the building, including the communal lounges, dining rooms and some of the service user’s bedrooms. Some of the records were also looked at, including staff files, accident and fire log book. The inspection particularly focussed on four service users with very different needs and looked at what it was like, from their point of view, living in Thornbury Care Centre. This involved talking with those service users and some of their relatives, observing staff’s care practices with them and checking that information obtained from discussion and observation was accurately recorded in the care records. This is known as case tracking. What the service does well: What has improved since the last inspection? The manager now always makes sure that she gets an assessment and/or care plan from the social worker. She also takes time to meet with people before they are admitted to the home to make sure that Thornbury Care Centre is the right place for them. Care plans have been introduced for every service user providing staff with information on how best to meet the service users needs. Medication procedures are much better so service users can be assured they will get their prescribed medication. Some of the staff practices have improved to promote the service users privacy. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 6 The manager makes sure that all complaints are fully investigated. The gardens have been tidied up and inside the home is much cleaner. The manager has looked at staff training and has plans in place to make sure everyone gets the training they need. The manager now makes sure that she interviews all potential staff. Service users and relatives said that they had noticed that things had improved. What they could do better: The home’s brochures need to tell prospective service users where people with dementia will be accommodated so that they can decide whether this is the best place for them to live. The manager should write to prospective service users, before they are admitted to the home, to let them know that the home can meet their needs. Although care plans have improved some need a bit more information in them to make sure that service users receive continuity of care. This is especially important so staff know how best to help those people, who, as a result of their dementia, become agitated. Staff must make sure that they treat the service users with dignity and respect at all times and they need to make sure that people with dementia are helped to make choices and have control over their own lives. The menus need sorting out as service users are not always provided with a varied diet. The quality of the meals also needs looking at as service users said that some of the food was poor. Staff need training so that they know what to do should they witness or suspect abuse. Some parts of the home, for example, the toilets and bathrooms, have not been well maintained. The boiler also needs looking at as some parts of the home are not kept warm enough when it gets cold. The smoking policy needs looking at and designated smoking areas need sorting out as people smoke in areas used by people who do not smoke. The manager needs to look at how the environment upstairs can be improved for people with dementia. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 7 Although staff recruitment procedures are better further improvements need to be made to make sure that only suitable people are employed to work in the home. Staff need 1:1 meetings with a senior member of staff, (known as a supervision), to make sure that they are carrying out their job well. Service users need to be asked their views about the services provided in the home and what they say needs to be acted upon. The manager also needs to carry out more regular checks to make sure that the home is running properly. New staff need a fire instruction on their first day in the home so that they know what to do if there is a fire. 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. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3&4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are not provided with sufficient information to decide whether the home can meet their needs. Although the admissions process generally ensures that service users are adequately assessed prior to care being offered, service users do not know that their needs will be fully addressed in the home. EVIDENCE: The manager always ensures that she obtains a copy of the social work assessment and or care plan before admitting a service user to the home. The quality of information within these varied and in one instance the information provided from the social worker could not be located. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 10 For planned admissions the manager always meets prospective service users to complete the home’s own assessment documents prior to their admission, however, she does not write to the service user confirming with them that having looked at the assessment, the home is able to meet their needs. The home is registered to provide a service for up to 23 people who have dementia. The majority of people who have dementia live on the first floor of the home, however, service users said that there were a number of people with dementia accommodated on the ground floor and that they had not been informed of this prior to moving to the home. The Statement of Purpose and Service User Guide do not inform prospective service users where the 23 people with dementia will be accommodated. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans have much improved but further develoment is needed to fully reflect the service users health and care needs and to ensure that the staff provide continuity of care. Medication is administered following recognised good practice, and auditing arrangements are in place, which protect the health and welfare of the service users. Improvements have been made to ensure that for those people with dementia their right to privacy is preserved, however, their dignity is not fully promoted. EVIDENCE: European Care, the organisation who own Thornbury Care Centre, have a standardised case file format and this has been introduced for every service user. Care plans sampled as part of the “case tracking” process covered a range of health and personal care needs including the support people need Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 12 with personal care, mobility, and mealtimes. Nutritional and falls assessments are completed and plans developed where needs have been identified in this area. Although specific information had been recorded in one person’s care plan about their wish to continue to use their own chiropodist and for their relatives to attend to their clothing, relatives said that often staff did not follow this guidance. In other care plans sampled some key information was missing, for example; details of the actions staff should take when people, as a result of their dementia, become agitated. Monitoring charts are completed for those people who have needs in relation to nutrition. However, the entries made on the recording sheets do not provide enough information from which to successfully monitor whether or not food and fluid intake has been sufficient. The deputy manager is reviewing the format of the recording sheets in order to address this issue. The staff complete daily records, however, recordings such as “fine today” and “poor diet” do not provide the information needed to evaluate whether or not the care plans are addressing the service user’s health and personal care needs. Entries such as “creamed bottom” do not promote the dignity of service users. Case tracking confirmed that although risk assessments are carried out for issues such as smoking they do not promote a person centred approach to care. For example, the same corporate form is completed for those people who smoke independently and those people for whom the staff look after their cigarettes. The risk assessment and strategies in place to minimise the risk do not identify whether or not people are able to look after their own lighter and if not why not. They also do not indicate whether staff should sit with individual service users whilst they smoke. A record is maintained of GP and other health care professionals involved with the service users’ health care. However, service users said that they had not seen a chiropodist for some time and were concerned about the condition of their feet. The deputy manager confirmed that she was aware of this issue and that a chiropodist has been arranged to visit the home. Medication is handled and administered by senior care staff who have received training in the safe handling of medication. Medication rounds take place during the morning, at lunch time, tea time and in the evening. A monitored dosage system is used, whereby the dispensing pharmacist supplies a month of each service user’s medication within a sealed pack. Printed ‘medication administration records’, (MAR), are also supplied by the pharmacist. The records examined for those people chosen to case track were generally in good Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 13 order, however, in five instances there was a gap on the MAR sheet where staff had not signed for administering the medication. The manager carries out regular audits of the MAR sheets in order to address this issue. This was evident from the yellow “post it” slips pointing out to staff where they had failed to sign for the medication they had administered. A service user who has dementia and shouts out has been prescribed “as and when” paracetamol in order to determine whether their behaviour is as a result of being in pain. The deputy manager agreed that the appropriateness of “as and when” pain relief in this situation needed to be reviewed as there was no guidance in place to advise staff of when this should be administered. The public telephone is no longer left in a service user’s bedroom and bedroom doors are no longer kept locked on the first floor of the home where people with dementia are accommodated. This means that people can spend time in the privacy of their room if they so choose. Throughout the inspection staff were generally observed to be respectful and courteous towards the service users. However, at lunchtime, a member of staff sat in between two service users assisting both of them at the same time with their meal, which is undignified. One relative commented about the staff being a little “rough” when assisting their family member with their personal care and other relatives said that the staff removed the clothing from their family member in “one go”, as often they found undergarments tangled with outer clothing, a practise which is neither respectful or dignified. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Arrangements to provide activities and occupation have improved providing opportunities for the service users’ to lead an active fulfilling lifestyle. Service users are able to maintain family and other contacts should they wish. This can help ensure they do not become socially isolated. Staff do not actively encourage service users with dementia in exercising choice and control over their lives thereby limiting their independence. Service users do not receive a good, varied choice based, menu. This can potentially limit the service users general health and wellbeing. EVIDENCE: An activities co-ordinator has recently been appointed. They are currently in the process of developing an activities programme and are taking time to talk to each individual service user in order to find out their likes and past interests. Activities which have recently been introduced include baking Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 15 sessions, a Valentines meal, an outing to Thorney Close over sixties club, short walks out in the community, cinema afternoons and reminiscing sessions. With the warmer weather approaching plans are in place to use the company bus to take service users out on trips further away. A newsletter has been introduced to keep people informed of past as well as forthcoming events in the home. Everyone said that the number and range of activities have improved in the home. Friends and relatives regularly call to the home, and can visit their relatives in private. Where possible service users manager their own money and some are able to maintain a good level of independence. For example: one service user likes to clean their own room and do their own ironing. Service users, staff and relatives were generally not very complimentary about the quality and quantity of the meals, although one service user did say “the foods fantastic”. Everyone, including the staff, said that all that was provided for tea was a limited choice of sandwiches, which often comprised of tuna fish and sweetcorn. People commented upon the hard pastry and poor quality of the homemade scones. The mealtime experience for those people with dementia was not a pleasant one. At least four people need assistance to eat their meals, however, with only three staff available this meant that staff had to walk between people offering support and as previously mentioned where staff did sit with service users they supported two people at the same time. There was a long wait between the main meal and pudding being served. During this time some of the service users were clearly becoming agitated. One person, who was sitting in a wheelchair and dependent upon staff to assist them from room to room, kept shouting they “wanted to get out” and that they “couldn’t get out”. Some staff ignored their request whilst other staff tried to explain to them that they needed to wait for their pudding. One service user’s request to have a third drink was denied by staff. Staff practices at mealtimes were task orientated and did not promote independence. Staff were not always available to guide the service users and help them maintain their independent living skills. This meant that one service user, instead of drinking form a cup, was left to drink out of a milk jug. Another service user, when left to eat on their own, was unable to put appropriate quantities of food on their fork. When service users went to reach for items on the table which were hot staff responded to this in a negative way Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 16 by saying “ no no its too hot” rather than asking the service user if they could offer them assistance. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure, however, this is not easily accessible to everyone which may prevent some people from making a complaint. Complaints are handled appropriately and therefore service users and relatives are confident that their views will be listened to. Appropriate policies and procedures are in place to ensure service users are protected from abuse, although further staff training is needed to fully safeguard the service users. EVIDENCE: The service has a complaints procedure. However, there has been no change to the format of this and it continues to be provided in small print only. It is also displayed high up on en-suite doors and therefore cannot be easily seen. There have been nineteen complaints since the last inspection. The manager has investigated these, however, there was no record to confirm whether the complainant was satisfied with the outcome, which would be good practise. The home has its own policy and procedure documents relating to abuse which are available to staff to guide them if they have any concerns in this area. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 18 However, it could not be established from training records whether staff have received training in the local authority safeguarding adults procedures, (formally known as Protection of Vulnerable Adults (POVA)). Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 19 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): 19,20,21,25&26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Thornbury Care Centre offers service users a clean, comfortable “hotel” like environment. However, some parts of the environment are not safe, not well maintained and disabling for those people with dementia who live there. EVIDENCE: The home was found to be generally clean and staff demonstrated an awareness of infection control by using protective gloves and aprons appropriately. All bedrooms are single occupancy and all are provided with en-suite toilet and shower facilities. Those viewed had been well personalised with the service users own possessions to make them feel like home. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 20 A number of maintenance issues were identified during this visit. For example: two radiator guards had come loose from the wall along the corridor on the first floor of the home, a bedroom door could not be easily closed as it was jammed open by the bedroom carpet and the lock on the toilet of the first floor of the home was stiff and could not be easily used. The paintwork in the toilets on the first floor was dirty and in need of redecoration. Some attempts have been made to re-decorate the bathroom on the first floor but this has only been half completed with only part of a wall having been painted. This area was also being used inappropriately as a store creating a potential trip hazard. People with dementia are accommodated mainly on the first floor of the home. Attempts have been made to help the service users find their rooms by placing large photographs of that person on their bedroom door as well as their name in large print. However, many of the photographs are of the person as they are now, which may not be appropriate for many people with dementia as they may not recognise themselves. A negative aspect of the environment, raised during previous inspections, is the call system. Each time this is activated by a service user, or member of staff, the noise resounds throughout the home. During lunch the call system was activated regularly which meant that service users were constantly subjected to this noise. This type of noise can have a negative impact on the comfort of the service users, particularly for those people with dementia and may make people irritable and result in “challenging” behaviour. A number of free standing radiators had been fixed high upon the walls of people’s bedrooms. The flex attached to these was hanging down the wall and could be easily reached. The deputy manager said that when the weather had been cold, the heating within ceratin parts of the home was insufficient and as such this action had been taken in an attempt to address this. The deputy manager said that the radiators had not been used for some time and due to the potential risk of such a device hanging upon the wall, particularly in an area where people with dementia are accommodated, agreed to have them removed. Service users have access to a pleasant garden area, which has been well maintained. They also have access to a choice of communal areas and some people liked to spend time sitting in the foyer of the home watching the comings and goings. An issue raised during previous inspections relates to the provision of a designated smoking area. The deputy manager confirmed that one lounge on the first floor was the designated smoking area, however, visitors and service users were observed to smoke in the dining area on the ground floor of the home. Both these areas also used by people who do not smoke and some Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 21 service users commented that they were not happy about this. Some people smoke in their bedrooms and although, as previously mentioned, risk assessments have been completed in relation to this, these are not sufficiently robust to ensure the safety of everyone living in the home. The development of such risk assessments should involve consultation with the fire authority. Another issue raised during previous inspections, which remains outstanding, relates to the layout of the bathrooms as staff have commented that they are not able to use moving and handling equipment safely. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are inadequate and a potential risk to the health and safety of the service users. Staff are properly trained and sufficiently experienced, however, staff recruitment processes do not fully protect the service users. EVIDENCE: There were three staff on duty on each floor of the home. Staff and visitors said that they thought that there were not enough staff. As previously mentioned at lunchtime there were not enough staff to assist people resulting in staff practices which compromised the dignity of the service users. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 23 Case tracking confirmed that there are at least three people who live on the first floor of the home with high care needs. When one service user does not receive 1:1 support they shout. This increases the noise levels in the environment which, as previously mentioned, is very disabling for people with dementia. Two other service users can become agitated and they require at least 1:1 support at such times. On the ground floor of the home there are eight people who use a wheelchair and need the support of two staff with their personal care. One relative complained to the deputy manager that there were no staff available to give their family member assistance when they needed it. An immediate requirement notice was issued to the deputy manager in relation to staffing levels and the Commission for Social Care Inspection have since been informed that staffing levels have been increased to four on the first floor of the home. Staff work twelve hour shifts and although they are provided with a break during this period of time, sometimes, if they are required to accompany a service user to hospital, which was the case on the day of the inspection, they may not be able to take their break until late in the day. Some of the staff work twelve hour shifts for four days in a row without a day off. Such shift patterns are not considered good practise when working with vulnerable people. Since the last inspection there has been a heavy dependency upon agency staff. However, the home is now fully staffed and visitors, service users and staff commented that there had been no agency staff working in the home for the last couple of weeks. The manager has completed a training needs analysis. Where there are gaps in staff training she has plans in place to address this. Some of the staff have completed training in dementia. Further training has been arranged in this area. Although only nine out of twenty six staff have achieved the NVQ level 2 training in care, the majority of the remainder of staff are currently undertaking this qualification. There has been a large turnover of staff in the home and consequently a large number of staff have been recruited. In the staff recruitment files examined in one there was no reference available from the person’s last employer and in a second file there was only one reference available. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 24 The Protection of Vulnerable Adults list is checked before new staff are able to work with service users and whilst awaiting receipt of a satisfactory Enhanced Criminal Records Bureau check new staff do not work unsupervised within the home. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36&38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users welfare is promoted by a well managed home. Procedures are in place to safeguard the service user’s finances. Staff are not provided with regular supervision and therefore the best interests of the service users are not fully safeguarded. Internal quality assurance systems have not been developed to an adequate level to ensure that the home is run in the best interests of the service users. The health, safety and welfare of service users is generally promoted, however, the frequency of fire instruction does not fully protect people. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 26 EVIDENCE: Since the last inspection a new manager has been appointed and has been registered with the Commission for Social Care Inspection. She has many years experience of managing registered services and is competent to run the home. There are clear lines of accountability in the home and a positive development has been the recruitment of a deputy manager. Staff said that they had not received regular supervisions. Appropriate records are maintained of accidents and the manager monitors the occurrence of these for each service user by introducing individual falls analysis forms. All new staff are provided with an induction which includes the provision of information and training on health and safety matters including fire safety, however, one member of staff said that they had not been provided with a fire instruction on their first day in the home. The manager has completed a fire risk assessment. Relatives meetings have been introduced and the manager has introduced internal regular audits of the medication, care plans and personal allowance. However, service users said that they have not been asked for their views on the running of the home. Although European care have a thorough internal continuous self-monitoring system, this is yet to be implemented within Thornbury Care Centre. Service users have the opportunity to manager their own money and facilities are provided to help keep it safe. Money held on behalf of service users is stored securely and detailed records of expenditure incurred maintained. Other than those issues discussed within the environment section of the report there were no other noticeable risks to the health and safety of the service users. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 27 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 2 X 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 2 X X X 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 X 2 Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5 Requirement The Statement of Purpose and Service User Guide must stipulate where within the home the 23 people who have dementia will be accommodated. The manager must write to prospective service users confirming to them that having regard to their assessment the home is able to meet their needs. Care plans must continue to develop to provide staff with step by step guidance on the action they must take to meet the service users psychological and health care needs. Service users must be treated with dignity and respect at all times. (Timescale not met 31/10/06). Staff practices must promote the principle of independence and choice Service users must be provided with a varied wholesome menu which reflects their likes and choices. The complaints procedure must be made accessible to all service DS0000063778.V330267.R02.S.doc Timescale for action 31/07/07 2. OP4 14(1)(d) 31/07/07 3. OP7 15 31/07/07 4. OP10 12(4)(a) 31/03/07 5. 6. OP14 OP15 12(1)(a) 16(2)(i) 31/03/07 31/05/07 7. OP16 22(6)17(2 ) 30/09/07 Thornbury Care Centre Version 5.2 Page 29 8. OP18 13(6) 9. 10. 11. OP19 OP19 OP19 23(2)(b) 13(4( c ) 23 12. 13. OP19 OP20 OP19 13(4)( c ) 12(2),12( 3)&13(4) 14. OP25 23(2)(p) 15. 16. 17. OP27 OP29 OP33 18(1)(a) 19 24 users and be available in a format suitable to those people who have a visual disability. (Timescale not met 31/10/06) All staff must receive training in relation to the prevention of abuse. (Timescale not met 31/10/06). Maintenance issues identified in the report must be addressed. The constant noise of the call system must be addressed. (Timescale not met 30/11/06). The environment must also be improved based upon current good practise for people with dementia. Bathrooms must not be used as store areas. If it is the policy of the home that people can smoke there, separate designated smoking areas must be provided. Robust risk assessments must be put in place, involving the fire authority, if it is the policy of the home for people to smoke in their bedrooms. (Timescale not met 31/03/06&31/10/06) The temperature throughout the home must be maintained at approximately 21 degrees centigrade at all times. Staffing levels must be kept under review to reflect the needs of the service users. Staff recruitment procedures must be improved as discussed within the body of the report. Systems must be put in place to obtain the views of service users and their relatives and to measure the home’s success in meeting its aims and objectives. (Timescale not met 31/03/06&31/12/06). 30/09/07 31/05/07 30/04/07 31/07/07 27/02/07 30/04/07 27/02/07 27/02/07 31/05/07 31/07/07 Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 30 18. 19. OP36 OP38 18(2) 23(4)(e) All staff must be appropriately supervised. (Timescale not met 31/10/06). The manager must ensure that all new staff receive a fire instruction on their first day of employment within the home. 31/05/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP15 OP21 Good Practice Recommendations A review of the mealtime arrangements should be carried out to ensure that this is a relaxed enjoyable experience for all service users. Consideration should be given to the layout of the bathrooms to ensure that staff and service users can safely use the moving and handling equipment. Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Thornbury Care Centre DS0000063778.V330267.R02.S.doc Version 5.2 Page 32 - 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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