Inspection on 15/11/05 for Thornbury Residential Home

This inspection was carried out on 15th November 2005.

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 Residential Home 27/05/08

Thornbury Residential Home 30/05/07

Thornbury Residential Home 20/04/06

Thornbury Residential Home 12/01/05

Thornbury Residential Home 08/10/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Thornbury Hempstead Road Uckfield East Sussex TN22 1DT Lead Inspector Kevin Whatley Unannounced Inspection 15th November 2005 10:00 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 DS0000021270.V253089.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thornbury Address Hempstead Road Uckfield East Sussex TN22 1DT 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) 01825 765502 01825 769852 Mr John Johnson Mrs Alyson Johnson Mrs Alyson Johnson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of nineteen elderly people to be accommodated (19) Service users must be aged 65 years and over on admission Date of last inspection 3rd May 2005 Brief Description of the Service: Thornbury is a residential care home providing personal care and accommodation for 19 older people, being situated in walking distance from the the town centre of Uckfield. The registered proprietor has owned and managed the home for over 19 years. The property is a two storey detached house with a stair lift for access between the floors. All service users benefit from single bedrooms, 5 of which have en-suite facilities. There is a pleasant garden at the front of the building that is well maintained with garden furniture available during fine weather. The home also has a patio at the rear, both the garden and patio have good access for residents. The home is attractively decorated and has a large conservatory leading off from the main lounge. In addition there is a courtyard in the centre of the home. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Thornbury will be referred to as ‘residents’. The unannounced inspection took place on a weekday in November and lasted for approximately five hours. At the time of the inspection Thornbury was accommodating seventeen residents. The inspection included a tour of the premises, both inside and out, and it’s facilities; many residents also agreed for their bedrooms to be viewed. The Inspector spoke with the proprietor/manager, the senior carer, two members of care staff and the cook. Approximately six residents were spoken to during the inspection; whilst care staff were observed carrying out their duties. A number of records and documents required by registration were also seen. What the service does well: What has improved since the last inspection? Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 6 Since the last inspection the information provided by the home has been reviewed and updated. The home have continued to develop the activities programme and have recorded risk assessments for those who venture out alone. The up grading of the first floor bathroom is now completed. Care staff have now all had appraisals completed by the proprietor/manager, whilst a formal supervision system has now been explored and identified. The proprietor/manager now has a more appropriate office that subsequently allows for the better storage of records and documentation. 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. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. Thornbury provides basic information about the home and the services it offers. Since the last inspection the recording procedures for the assessment and admittance of new residents has improved. EVIDENCE: The homes statement of purpose outlines the services Thornbury offers prospective residents including the location of the home, the homes philosophy of care, the times of meals, and extras that are not included in the fees, such as chiropody and hairdressing. Since the last inspection the home have reviewed their information and have now included the details of the physical layout of the home. Information relating to residents who had been admitted since the last inspection confirmed that the proprietor/manager visits prospective residents and subsequently carries out care needs assessments. Such assessments covered all relevant areas of care such as their physical, emotional, and health care needs. Documentation contained evidence of risk assessments being completed including issues of mobility, handling and lifting, health and diet. Where necessary pre-admission information contained assessments from other Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 9 care professionals such as Occupational Therapists and G.P’s. The most recent referral to the home was seen to contain considerable information regarding the prospective resident and subsequently the proprietor/manager had completed a comprehensive care assessment, risk assessments and care plan. Residents noted that they had been consulted during the admission process, whilst records confirmed that the relatives/carers and other concerned persons are actively involved and encouraged to visit the home prior to the resident being admitted. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10. The individual needs of residents are suitably assessed and incorporated into appropriate plans of care. The home must ensure that they comply with their own policies and procedures and those of legislation in respect of medicine storage and administration. Residents are treated with respect, dignity and care. EVIDENCE: A number of care plans were viewed, notably those relating to recently admitted residents. All care plans contained relevant information such as medical history, social history, current health care issues and emotional well being. Such information was incorporated into plans of care focusing on the manner in which the assessed needs should be met by care staff whether they be personal care matters such as bathing and dressing or general care issues such as diet and mobility. Care plans also contained relevant risk assessments, these were found to be clear, concise, and relevant. A staff ‘handover’ was observed between morning and afternoon staff. This was seen to be appropriate with information regarding issues affecting all residents being passed on to the ‘on-coming’ shift. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 11 Since the last inspection the home have addressed an outstanding risk assessment regarding pets and residents when they are outside of the home unaccompanied. The homes medicine storage and administration system was viewed. A number of errors were found within the medicine administration records, notably where medicines had already been administered but not recorded. A number of care staff also noted that they had been administering medicines although they had not received appropriate training, whilst night staff had ‘put out’ medicines into pots prior to day staff administering these when they come on duty. The proprietor/manager accepted that these practices should not be occurring and stated such errors would be addressed ‘immediately’. Staff were seen to interact with residents in a relaxed and respectful manner, including knocking on bedroom doors prior to entering and being patient and considerate in the provision of support, assistance and guidance. Residents stated that the care they receive is ‘second to none’ and that when they need assistance the care staff are ‘there to help’. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15. The home provides residents with opportunities to engage in group activities and events, whilst individual interests are addressed. Residents benefit from appropriate routines and a suitable visitors policy. The dietary needs of residents are met. The kitchen area must remain free from hazards to the health and safety and hygiene of residents and staff alike. EVIDENCE: The home advertises the times of meals and activities around the building and these were seen to take place at reasonable periods of the day. Residents stated that the daily routines of the home were ‘relaxed’ and suited to their needs. The home have a programme of activities that covers five days of the week, with certain days being set aside for specific events and activities. Most of the activities are facilitated by visiting activities co-ordinator’s. During the inspection an activities co-ordinator was facilitating an activity in the lounge area. This involved a board game and it was clear that the residents who had attended the event were enjoying the interaction and stimulation. The coordinator explained that she is employed to visit the home three mornings a week and provides a number of different activities such as quizzes, bingo, and exercise sessions. The co-ordinator also noted that she attempts to involve residents who do not feel they wish to engage in group activities and Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 13 subsequently ensures that a certain amount of her time is spent every visit offering opportunities to these residents to pursue their own interests. On the day of the inspection one resident had been supported by the co-ordinator and a member of care staff to produce a personalised ‘get well’ card for a friend. One resident attends a weekly day centre, whilst several others are able to visit the local shops on their own on a regular basis. One resident stated that they had been taken out to the ‘Remembrance Day’ parade the previous weekend which they had ‘thoroughly enjoyed’. The visitor’s book and daily log book were seen to contain evidence of regular visits being made to residents by family and friends. The home have a relaxed approach to visitors and residents commented that they can be visited ‘whenever they wish within reason’. The Inspector was invited to have lunch with residents. The meal took place in the pleasantly decorated dining area and was found to be well prepared and presented, tasty and home cooked. Residents commented positively on the food they receive at the home and noted that the ‘food is really good’. The menu held in the kitchen provided evidence of residents receiving a varied and balanced diet, though the one displayed in the dining was out of date. Of concern during the inspection was the occasional presence of the proprietor/managers dogs in the kitchen area. The proprietor/manager stated that if they are in the home they normally reside in the office, though she accepted that they potentially posed a health and safety and hygiene risk if they are in the kitchen. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The home have a suitable complaints procedure in place though they must ensure that residents concerns are addressed by the appropriate person without delay. Adult protection concerns are addressed through the homes policies and procedures and residents benefit from appropriate intervention when required. Care staff should be made fully aware of adult protection procedures. EVIDENCE: The home have a suitable complaints procedure which clearly outlines it’s responsibility for addressing any concerns or complaints made about the home, it’s staff, or the service it offers. A copy of this policy and procedure was clearly displayed in a communal area of the home. The complaints book was viewed. This was found to contain two complaints from residents, one was seen to have been appropriately addressed by the proprietor/manager. However the most recent complaint had not been addressed. The proprietor/manager stated that she had not had this matter brought to her attention by her senior care staff, but that she would speak to the resident in question ‘today’. CSCI have not received any complaints concerning Thornbury since the last inspection. The home have appropriate adult protection policies and procedures in place, including a policy on ‘whistle blowing’. Staff files indicated that adult protection issues are addressed in their induction programme and staff spoken to displayed a basic understanding of relevant adult protection concerns, though their knowledge of procedures in the event of an allegation was somewhat limited. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 15 Since the last inspection there has been one alleged adult protection matter at the home. However following a full investigation the matter was found to be unsubstantiated. Whilst the management team and care staff were seen to have acted entirely appropriately, the proprietor/manager was invited to attend a meeting with the CSCI to review the process for future reference. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24 and 26. Residents live in a homely and relaxed environment that is suitably maintained with the necessary facilities in place to meet their needs. Residents are protected from the risk of harm by the policies and procedures of the home. EVIDENCE: Thornbury is furnished with domestic style fittings and carpets and was found to be warm and airy, with a satisfactory level of natural and artificial light. Several residents agreed to have their bedrooms viewed. These were found to be clean and well maintained and had been individualised by the resident with personal items such as photographs, pictures, and ornaments. Thornbury is well maintained both inside and out, with a satisfactory standard of decoration visible throughout the home. The home was found to be clean, tidy, and free from offensive odours or smells; however as previously noted the presence of the proprietor/managers dogs in the kitchen area posses some obvious concerns. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 17 Since the last inspection work to upgrade a first floor bathroom have now been completed. The work carried out is of a high standard and first floor residents now benefit from having full bathing facilities nearby. Work has also been completed to improve the office area; this now affords the proprietor/manager and other care staff a more pleasant and spacious environment that subsequently aids the storage of records and documentation. The homes stairlift was found to be in good working order. Fire records confirmed that regular fire alarm and emergency lighting checks had been completed, whilst the fire safety equipment had been recently serviced. Evidence of staff attending fire safety training was seen. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30. Thornbury deploy suitably experienced care staff in appropriate numbers to meet the assessed needs of residents, though staffing numbers should be kept under review. The home must comply with legislation in respect of the recruitment of staff to ensure residents are protected from the risk of harm at all times. EVIDENCE: The staff rota was viewed and this confirmed that during the daytime the home deploy a minimum of three members of care staff, with an additional member of care staff on duty during the busy morning hours. In addition to this the manager or deputy manager are also available during office hours. During the night the home deploy one member of care staff to carryout ‘waking night’ duties with either the manager, who lives nearby, or her deputy facilitating an ‘on-call’ system as support. Records indicate that many care staff employed at Thornbury have had previous experience in the care industry. The home have a suitable induction and training programme that addresses such areas as adult protection, safe handling and lifting, health and safety, first aid, and medicine administration for which certification has been given. Records also indicated that all care staff training needs and requirements have now been recorded, with evidence of further training planed for each member of care staff. The home have employed one member of staff since the last inspection. On discussing the appointment with the proprietor/manager it became apparent Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 19 that the new employee was a member of her family, however there was no evidence of a Criminal Records Bureau (CRB) check being completed prior to them starting work at the home. The proprietor/manager stated that there had been a ‘delay’ in receiving the CRB check back but acknowledged that she should not have allowed them to work until all documentation was in place. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36 and 38. The experience of the homes proprietor/manager ensures that residents needs remain of paramount importance. The management team must strive toward fully implementing a system of formal staff supervision, whilst all aspects of health and safety within the home must be reviewed. EVIDENCE: The provider/manager of Thornbury has been providing a residential care service for older people at the home for a considerable number of years and subsequently commands a vast understanding of the needs of residents. She is currently undertaking the National Vocational Qualification (NVQ) level 4 award in Care and Management and expects to complete this next spring. Residents stated that they felt they could ‘talk to the proprietor/manager should they have any concerns or complaints. The last inspection report noted that the management team needed to develop the system of formal supervision for care staff. Since the last inspection most Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 21 care staff have had appraisals completed by the proprietor/manager and these are suitably recorded. It is envisaged that the formal supervision of care staff will begin in the near future as the proprietor/manager is due to attend supervisory training as part of her NVQ course in the next few weeks. Despite the concerns previously noted (see standards 15 and 19) all other health and safety issues are suitably addressed and residents and staff alike are protected by up to date and accurate records such as environmental risk assessments, fire logs and electrical maintenance documentation; where necessary regular checks, including hot water temperatures, are carried out and recorded appropriately. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 22 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X X 2 X 2 Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 23 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 OP9 Regulation 13(2) Requirement The home must comply with their own policies and proecedures and that of legislation in regards the storage and administration of medicines. The management of the home must ensure that all areas of the home are free from risks to the health and safety and hygiene of residents and staff, such as the owners dogs being allowed in the kitchen area. The home must ensure that any complaints are passed to the appropriate person to investigate without delay. The proprietor/manager must not allow staff to work at the home prior to gaining confirmation of the required CRB checks being completed. That the manager obtains the NVQ level 4 award in Care and Management. That the management of the home must implement a suitable system of formal supervision for care staff (outstanding from previous inspections). DS0000021270.V253089.R01.S.doc Timescale for action 15/11/05 2 OP15 OP19 OP38 13(4)(a) 15/11/05 3 OP16 22(3) 15/11/05 4 OP29 19(1)(b) 15/11/05 5 6 OP31 OP36 8(2)(b)(i) 18(2) 15/05/06 15/05/06 Thornbury Version 5.0 Page 24 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 OP18 Good Practice Recommendations That the menu displayed in the dining room should be kept up to date. That the home should provide care staff with information/training relating to adult protection procedures in the event of allegations of abuse being made. Thornbury DS0000021270.V253089.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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 DS0000021270.V253089.R01.S.doc Version 5.0 Page 26 - 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!