This inspection was carried out on 28th May 2009.
CQC found this care home to be providing an Good service.
The inspector found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for older people
Name: Address: Thornbury Care Centre 58 Thorndale Road Thorney Close Sunderland SR3 4JG two star good service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Nicola Shaw Date: 2 8 0 5 2 0 0 9 Information about the care home
Name of care home: Address: Thornbury Care Centre 58 Thorndale Road Thorney Close Sunderland SR3 4JG 01915201881 Telephone number: Fax number: Email address: Provider web address: www.europeancare.co.uk Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : European Care (England) Ltd care home 44 Number of places (if applicable): Under 65 Over 65 0 0 21 0 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Conditions of registration: 23 6 0 10 The maximum number of service users who can be accommodated is: 44 Date of last inspection Brief description of the care home 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. Since the last inspection European Care have applied to the CSCI for a variation to the home?s registration to enable nursing care to be provided. This application was approved in October 2007.
Care Homes for Older People Page 2 of 10 Brief description of the care home The home is built on a sloping site with accommodation for service users over two floors, with a service area on the lower ground floor. Accommodation consists of two lounges, dining room and bathroom on each floor. A passenger lift serves the first floor, which specifically provides accommodation for people with dementia. 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 £381-£442 for residential care and £502 for nursing care. Care Homes for Older People Page 3 of 10 What we found:
This random inspection was carried out by Nic Shaw and Sam Doku, regulation inspectors, in response to an anonymous complaint which we received on th 18th May 2009. The complainant raised issues about staffing levels and a lack of supply of protective gloves, aprons and continence aids. We met with the manager and homes line manager. The manager confirmed that there are 42 people in the home with 3 people in hospital. Current staffing levels are 3 care staff on each floor plus a nurse on each floor until 2pm. After 2pm there is only one nurse plus 6 care staff for both floors. There are 22 people living upstairs who the manager described as having high care needs. Although the manager said that she was hoping to increase staffing levels to 4 upstairs after 2pm in June 2009, 3 care staff is insufficient to meeting the needs of 22 people with high care needs. We looked at staffing levels on the night of 24th May 2009, when a service users was admitted to hospital following a fall. On that night there was an agency nurse in charge of the home plus 3 care staff, one of which was also an agency member of staff. The manager said that she was not aware that on this evening half of the staff were agency staff. She also said that she was also not aware that an agency nurse, who had never been to the home before, was left in charge . During that night a service user had to be admitted to hospital in an emergency. The agency staff nurse had contacted the relatives to ask them to go to hospital and told them that staff from Thornbury care home could not as they were short staffed. The manager had not been informed of this emergency situation. We talked to the manager about the concern raised about an insufficient supply of continence aids. She confirmed that service user are only assessed and provided with 3 incontinence aids per day by health care professionals. As such the home purchases additional continence aids for service users. We looked at the supply of protective gloves and aprons. There was a good supply of these in the home. What the care home does well: What they could do better:
Staffing levels need looking at on the late shift, but also during the night. The manager agreed to immediately provide an additional member of staff on the late shift. The homes policy about leaving agency staff in charge of the home at night and what to do in an emergency situation, for example, when a service user has a fall during the night, also needs looking at.
Care Homes for Older People Page 4 of 10 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 10 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 3 14(1)(b) Where service users are 27/05/2008 funded by the Local Authority or Health Authority, the manager must obtain a copy of the assessment and care plan completed by them, prior to admitting prospective service users. This is to ensure that the home is able to meet their needs. 2 7 15 Care plans must continue to 27/05/2008 be reviewed and up-dated as planned so that continuity of care is provided to service users at all times. ( Previous timescale not met 31/07/07). 3 9 13(2) Monitoring systems must be 27/05/2008 put in place to ensure that service users who administer their own medication continue to do so with the correct support they require. The manager must investigate why two tablets could not be accounted for during the brief medication audit and take action as Care Homes for Older People Page 6 of 10 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action necessary to prevent a reoccurrence. 4 12 16(2)(m) Opportunities must continue to develop for service users to take part in a range of social and community activities, including those that meet each individuals religious needs. This is to ensure the well-being of the service users. 27/05/2008 5 16 17(2) Schedule 4 A record of all complaints 27/05/2008 must be maintained together with the action taken by the manager to address these. This is to assure people that their views are listened to and acted upon. 6 18 13(6) The manager must refer all 27/05/2008 allegations of abuse in accordance with the Local Authority safeguarding adults procedures. This is to ensure that service users are fully protected at all times. 7 30 18(1)( c )(i) The manager must complete 30/08/2008 the training needs analysis for staff as planned. A copy of this together with details of the training programme for 2008/2009 must be
Page 7 of 10 Care Homes for Older People Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action forwarded to the CSCI. This is to ensure that service users benefit from staff who are trained and competent to do their jobs. 8 36 18(2) All staff must be appropriately supervised. (Timescale not met 31/10/06& 31/05/07). 27/05/2008 Care Homes for Older People Page 8 of 10 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 27 18 Staffing levels need to be reviewed during late afternoon, evening and night. This is to make sure the health care needs of the service users can be effectively met. 30/06/2009 2 27 33 The manager must review 30/06/2009 the homes policy for leaving agency staff, who are unfamiliar with the home, in charge. This is to make sure that the health and welfare of the service users is protected. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 33 The manager should review the homes policy about action staff should take if there is an emergency during the night. Care Homes for Older People Page 9 of 10 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 10 of 10 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
