Inspection on 09/11/07 for Thornbury Care Centre

This inspection was carried out on 9th November 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 26/02/07

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 Key Unannounced Inspection 10:00 9 &16th November 2007 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.V354378.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. Thornbury Care Centre DS0000063778.V354378.R01.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 Janice Taylor (not yet registered) Care Home with nursing 44 Category(ies) of Dementia (23), Mental disorder, excluding registration, with number learning disability or dementia (6), Old age, not of places falling within any other category (21), Physical disability (10) Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE, maximum number of places: 23 Old age, not falling within any other category - Code OP, maximum number of places: 21 Physical Disability - Code PD, maximum number of places: 10 Mental Disorder, excluding learning disability or dementia - Code MD, maximum number of places: 6 2. The maximum number of service users who can be accommodated is: 44 26th February 2007 Date of last inspection 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. 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. 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 ensuite 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 Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 5 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. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • information we have received since the last full visit on 27th February 2007. • how the service has dealt with any complaints & concerns since the last visit • any changes to how the home is run • the provider’s view of how well they care for people • the views of people who use the service and their relatives and staff. The Visit: An unannounced visit was made on 9th &15th November 2007. During the visit we: • talked with people who use the service, relatives, staff, the manager & visitors • joined service users for a meal and looked at how staff support the people who live here • looked at information about the people who use the service and how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills and training to meet the needs of the people they care for • looked around parts of the building to make sure it was clean, safe and comfortable • checked what improvements had been made since the last visit. We told the manager what we found at each visit. What the service does well: The home supports people to have good access to any health care that they need and offers them a clean comfortable place to live. Friends and relatives are able to visit their family member at any time. The manager understands the needs of people with dementia and knows how to ensure staff provide a service that respects their individuality and promotes their dignity. Staff training is good and as well NVQ level 2 and 3 training in care being provided, 12 of the staff have had specialist training in the needs of people with dementia. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 7 Service users said: “the staff are lovely” Relatives said: “the staff are always nice, they ask visitors if they would like a cup of tea” Staff said: “Janice (the manager) is really understanding and sorts things out”. What has improved since the last inspection? The manager now writes to service users confirming with them that having looked at their assessment, the home is able to meet their needs. In this way service users are assured that Thornbury Care Centre is the right place for them. The needs of some of the service users living on the ground floor have also been re-assessed to make sure that they are receiving the right type of care. The majority of staff are now excellent at making sure service users, particularly people with dementia, are treated with dignity and respect. This is especially apparent at mealtimes which is now a relaxed social occasion, where staff sit with people chatting to them about their social history. A new care plan format has been introduced which provides lots of good information about the service users care needs. The complaints procedure is now available in large print so that people who have a visual disability can read this more easily. Care staff have also had training in safeguarding adults, so that they know what to do should they witness or suspect abuse. There is now a full time maintenance person and some areas of the home have been redecorated. There have been improvements to the environment where people with dementia live. This area is now much more homely, with pictures and paintings along corridors. It is also much quieter, which is really important for people with dementia as too much noise can lead to some people becoming agitated. Visitors and service users can no longer smoke in communal areas and the heating has been improved on the top floor of the home. Staff recruitment procedures are much better and this ensures that only suitable people are employed to work in the home. All staff have been provided with fire training and know what they should do in the event of a fire. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 8 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. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 9 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.V354378.R01.S.doc Version 5.2 Page 10 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 People who use this service experience good outcomes in this area. Good assessment processes ensure that potential service users’ needs can be met and people receive sufficient information about the service to help them make an informed decision about whether to move in. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: For those service users funded by the Local Authority or Health Authority, before they move to the home, they are assessed by a care manager of the Social Services Department or a nurse assessor. However, the manager does not always obtain a copy of the social work or health assessment and care plan prior to their admission. Senior staff always visit prospective service users to carry out the home’s preadmission assessment. Wherever possible, service users and their relatives are encouraged to come and have a look around the home prior to their move. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 11 The manager also writes to the service user confirming with them that having carried out her own 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. As part of the home’s application to register to provide nursing care a new Statement of Purpose and Service User Guide were developed. These documents advise prospective service users about the services and facilities available as well as where people with dementia will be accommodated. However, these documents do not inform prospective service users that the home provides a short break service. As part of the re-registration of the service the needs of some of the service users living on the ground floor were re-assessed to make sure that people were placed appropriately. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 12 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 People who use this service experience good quality outcomes in this area. Overall, service users have good support with personal care and good access to health care services, where the privacy and dignity of people with dementia is upheld to an excellent standard. However, care plans need further development to ensure that continuity of care is provided. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager and senior staff are currently in the process of introducing a new assessment and care planning process. This involves undertaking a number of detailed, comprehensive assessments including nutrition, manual handling and falls risk assessments when a service users first moves into the home. From this information the care plan is developed. An example of the new care plan format provides good information about the person and was written in a person-centred way. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 13 The “modified Cohen-Mansfield agitation inventory” is a tool used by the company to assess a person’s level of agitation. Some of the language used in this assessment tool undermines the person centred approach which is clearly being adopted in this home. This was discussed with the manager and senior staff who agreed to review its use. Information in other service users care plans examined was not up-date. For example; one service users health care needs had significantly changed, however, the care plan had not been reviewed to reflect this. Some of the entries in daily recordings did not reflect the actual care that was being delivered or sufficient information to be able to evaluate the care plans, for example; “no new changes, “ no problems”. The manager agreed that work needed to continue to bring all care plans up to date. Clear assessment of one service user’s mobility needs, and a subsequent analysis of falls, led to a referral to the specialist Falls Team. The home ensures that all service users are registered with appropriate community health care services, including GP, dental, ophthalmic and chiropody services. One relative commented that the staff always accompanied their family member to hospital appointments. Two service users and one relative expressed dissatisfaction with the personal care provided, such comments were in the minority. There are self-administration assessments for people who are able to manage their own medication. However, it was not clear in those examined what management strategies were in place to enable the service user to maintain their independence in this area. Since the last inspection the CSCI have been notified of three serious medication errors. The manager has dealt these with appropriately and as a consequence a detailed medication administration review has been carried out to establish staff competency in this area. As a result of this review the nurse in charge is now the designated person responsible for administering medication. There is secure, suitable storage for medication, and administration of medication was carried out correctly. A brief audit of the medication confirmed that generally medication had been administered appropriately to service users, however, in one instance two tablets could not be accounted for, and the senior staff in charge of medication agreed to investigate this. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 14 There is a good record of compliance with the receipt, administration, safekeeping and disposal of Controlled Drugs. Nurses have been given responsibility for checking each other’s work to make sure that there are no unexplained gaps on the Medication Administration Record, and records showed that this system is working well. During the inspection visits there were many instances of excellent practice where staff supported people with dementia in a sensitive and respectful way. For example, sitting with individual service users chatting with them as well as offering support at mealtimes, assisting people with their mobility at the service users own pace, and ensuring that health care visits were conducted in the privacy of the service users own bedroom. Service users are supported with their personal grooming and appearance. A weekly hairdressing service is available at the home, which several service users use. Staff made a point of complimenting one service user on their appearance following a visit to the hairdresser, which is important in terms of promoting a positive self image. One relative commented that their family member’s clothes were always “nice” and that hair was always “done”. Service users can use their own bedrooms for privacy whenever they wish. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 15 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 People who use this service experience good quality outcomes in this area. Service users have opportunities to make choices in daily routines and menus so that they lead a lifestyle that matches their individual preferences. However, further attention needs to be given to social and community activities and how the service user’s diverse religious needs can be met to ensure their well-being is fully promoted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The activities co-ordinator has been off sick for some time and consequently there hasn’t been much in the way of planned activities for service users. The majority of service users commented that “sometimes” there were activities in the home. Recently, a second activities co-ordinator has been employed by the service. She is in the process of gathering information about the service user’s life history so that an appropriate activities programme can be developed. The service users and their families are being involved in this process. She has also been in touch with the Dementia Development Centre to Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 16 obtain some ideas of appropriate activities for people with dementia. A trip out for Christmas lunch is being planned. At the moment there are limited opportunities for people who need support to use local community facilities such as Churches or the local community centre. Although a priest from a local Church visits the home once a month, one service user commented that they would love to be able to go out to their local Church. It was clear that for the majority of service users their emotional well-being is being supported by the interaction with staff and other service users in the home. One relative commented “ if I ever had to come into a home I would like it to be this one”. However, a small number of service users commented that they did not feel that their emotional needs were being met and this needs to be looked into by the manager. It was really positive to note that staff have an understanding of the importance of involving service users, particularly those people who have dementia, in activities of daily living. Service users are encouraged, for example, to help with the washing up after their meal. Friends and visitors are able to visit their family member at any time. The majority of people commented positively about the quality of meals and this is an area which the manager and senior staff are closely monitoring. . Comments received included “ the foods OK, I’m not fussy”, “ the foods nice”, “you get a lovely bacon sandwich”, and “the fish pie and peas today were smashing”. There are written menus on each table in both dining rooms that show that day’s menu choices. One service user took great pleasure in reading the menus for that week. The tables were beautifully presented with tablecloths napkins and condiments. The lunchtime experience for people with dementia was excellent. The staff on duty offered support to people who needed this in a sensitive, discrete manner. Staff also sat with those people who didn’t need support, chatting with them and encouraging them to talk about themselves. People were not rushed and were able to eat their meal at their own pace. One service user, when they had finished their meal, was encouraged by staff to show them his photograph album. This he did, an activity which other service users also clearly enjoyed, and in this way the mealtime experience was a sociable, relaxed occasion. Thornbury Care Centre DS0000063778.V354378.R01.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 People who use this service experience good quality outcomes in this area. Good complaints and protection procedures are in place, however, further improvements need to be implemented to fully ensure that service users and relatives know their views will always be taken seriously and dealt with effectively. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The service has a complaints procedure. This is available in large print and has been laminated and placed in each service users bedroom. Relatives and service users said that they felt able to complain and a number of them had done so, there have been 23 complaints in the last year all of which have been upheld. However, some of the concerns raised by them had not been recorded in the complaints record and the manager agreed that this was an area for improvement. One service user had complained to the manager about the apparent attitude of a member of staff towards another service user. Although the manager immediately carried out an investigation, and interviewed staff, there were no records available to confirm this or what action had been taken to fully safeguard people. The complaint was about alleged verbal abuse, however, a Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 18 referral had not been made to the Local Authority Safeguarding Adults coordinator. (The latter issue has since been addressed). There has been 1 safeguarding adults referral made in the last year. All of the staff are completing Level 1 “alerter” training and some of the staff have attended training in the Local Authority safeguarding adults procedures provided by the Local Authority. The manager and senior staff have also completed safeguarding adults training specifically for managers by the Local Authority. Thornbury Care Centre DS0000063778.V354378.R01.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 People who use this service experience good quality outcomes in this area. Overall the standard of decoration and furnishing in the home continues to improve so that service users enjoy good quality accommodation. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home was found to be clean, well maintained, with no unpleasant odours. All of the service users commented in the surveys that the home was either “generally” or “always” clean and one visitor commented that there were never any unpleasant odours. All bedrooms are single occupancy and all are provided with en-suite toilet and shower facilities. The manager has ordered paper hand towel dispensers which are to be fitted in all en-suite facilities. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 20 The bedrooms seen were comfortable, warm and well furnished. Many have been highly personalised by service users and their relatives, with their own bed throws, furniture and pictures. One person has their own fridge. Service users and relatives said that that the bedrooms were “nice”. Staff said that since the new manager has been in post they have seen improvements to the home. They said that the manager “gets things done” and commented that the decorators had recently been in and that “more was planned”. A full time maintenance person has also been employed. The service users have good access to the home’s garden with staff support, and there is some seating for them to enjoy in better weather. 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. There have been improvements to the environment for people with dementia. The corridors now have pictures and paintings, some of which have been created by the service users themselves. It is also much quieter upstairs and this is really important as noise can contribute towards agitation for some people who have dementia. There are also plans in place to split the call system so that each floor operates independently of one another. This will also contribute towards maintaining a calm environment. (In a separate meeting with the manager after the inspection the Commission were informed that this work has now been completed) The issue of service users and visitors smoking in communal areas throughout the home has been addressed. Service users who smoke do so in their bedrooms with appropriate staff supervision. The heating problem has also been addressed, however, it did feel cooler in the corridors of the top floor of the home where people with dementia are accommodated. An issue which remains outstanding from previous inspections, is the layout of the bathrooms. Staff have commented that they are not able to use moving and handling equipment safely. Nine of the staff have completed training in infection control and the manager plans to arrange for the remainder of staff to complete this training in the next 12 months. The home has recently been visited by the Environmental Health Department and no requirements were made as a result of this visit. Thornbury Care Centre DS0000063778.V354378.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 People who use this service experience good quality outcomes in this area. The home provides sufficient, competent, well-trained staff to ensure that the needs of the people who live here are met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home currently provides 3 care staff on duty on the ground floor and one nurse and 2 care staff on the first floor. There are no care staff vacancies at this present time. As there are 11 beds vacant on the top floor of he home this means that people with dementia who live there receive good levels of staff support where many opportunities are provided for engagement and interaction. The manager has reviewed the number of hours staff work in a day and has reduced many of these so that staff do not work more than 6 hours in a row. This is good practice as the 12 hour shifts, which some staff previously worked, increased the chances of staff becoming tired and therefore more likely to make mistakes. The home employs sufficient domestic, laundry and catering staff. The home also has an administrator (who manages administrative and financial matters). Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 22 It was clear that most service users enjoy a good relationship with staff. Service users said “ the staff are good”, “they are always polite”, “they are lovely” however, one service user commented that “staff are OK, some are alright, others not” and as previously mentioned a service user had made a complaint to the manager about one member of staff and their attitude towards another service user. European Care is an equal opportunities employer and promotes clear equality and diversity procedures when recruiting new staff. There is a mix of age, gender, experience, and nationality amongst the staff team. Staff records showed that suitable checks and clearances are received before any new staff are employed. It was clear from training records and from discussions with staff that European Care provides very good training opportunities. The training needs analysis clearly shows the courses that each member of staff has completed and the training that is planned for the next 12 months. Twelve staff have completed “Yesterday, Today, Tomorrow” training which is specialist training in dementia care provided by the Alzheimer’s Disease Society. The majority of staff have also completed either NVQ level 2 or 3 training in care. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 23 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 People who use this service experience good quality outcomes in this area. Overall the home is well-run, in a way that upholds the best interests of the people who live here, and ensures their health, safety and welfare are protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager has many years experience in health and social care settings. She is a Registered Mental Nurse (RMN) and has in depth knowledge of the needs of people with dementia. Staff said about the manager “”she mucks in”, “its (the atmosphere) much more relaxed” and a service user said “I like Janice she is very understanding”. Two people commented that they did not feel they Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 24 could approach the manager, however, their comments were in the minority and it was evident that since she has been in charge of the home significant improvements have been made, particularly for people with dementia. There are clear lines of accountability within the home and within the organisation. It was obvious that the home is well supported by the senior management of European Care. They visit the home at least once a month and report back to the organisation on the findings. Service users’ views are sought via satisfaction surveys. The home also holds service user/relatives meetings, although there has only been one this year, a second one is planned before Christmas. Some service users and/or their relatives continue to manage their own financial affairs and this is encouraged by the home. The homes administrator does support some service users with the safe storage of their personal monies, if they wish. These are stored individually. The handwritten records of transactions carried out by the home on behalf of service users are generally well managed. However, although receipts are obtained for all purchases made, often there was only one staff signature on the service user transaction sheet. Although the administrator carries out regular audits of the money, these are not regularly checked by the manager or senior staff within European Care. Supervisions have been introduced, however, the frequency of these needs to be at least every 2 months. A mentoring programme is being introduced for nurses. Staff receive training in statutory health and safety matters, so that they know how to support service users in a safe way and all staff have recently had fire training. However, some of the certificates were not available to verify this training. The manager is aware of this and plans to complete a full audit of staff training records. An appropriate record is maintained of accidents. The manager also monitors the occurrence of these which helps to identify any themes or trends for which preventable action could be taken. There are clear records of the maintenance and servicing of equipment (for example, the lift and electrical portable appliance tests) by external services. Maintenance staff check the water temperatures of baths every month. The frequency of this should be increased to at least weekly in order to ensure it is issued at the correct safe hot water guidelines of around 43°C. Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 25 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 X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 3 3 X X X 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 3 4 3 X 2 2 X 3 Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14(1)(b) Requirement Where service users are 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. Care plans must continue to 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). Monitoring systems must be 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 necessary to prevent a reoccurrence. Timescale for action 31/12/07 2 OP7 15 31/03/08 3 OP9 13(2) 31/12/07 Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 27 4 OP12 OP13 16(2)(m) 5 OP16 17(2) Schedule 4 13(6) 6 OP18 7 OP36 18(2) Opportunities must continue to develop for service users to take part in a range of social and community activities, including those that meet each individual’s religious needs. This is to ensure the well-being of the service users. A record of all complaints must be maintained together with the action taken by the manager to address these. The manager must refer all allegations of abuse in accordance with the Local Authority safeguarding adults procedures. All staff must be appropriately supervised. (Timescale not met 31/10/06& 31/05/07). 31/03/08 31/12/07 16/11/07 31/03/09 Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 28 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 OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should inform prospective service users that a short break service is provided in the home. 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. This is to ensure the safety of staff and service users. It is recommended the temperature in the top floor of the home be monitored to ensure that this is maintained at 21 degrees centigrade at all times. This is to ensure the comfort of service users. It is recommended that two staff or one member of staff and the service user or their relative sign the personal allowance transaction sheet. This is to ensure the financial protection of service users. It is recommended the frequency of hot water temperatures to baths and showers be checked at least weekly. This is to ensure the safety of service users. OP21 3 OP25 4 OP35 5 OP38 Thornbury Care Centre DS0000063778.V354378.R01.S.doc Version 5.2 Page 29 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. 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