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Inspection on 30/05/07 for Thornbury Residential Home

Also see our care home review for Thornbury Residential Home for more information

This inspection was carried out on 30th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Thornbury ensures that prospective service users and their relatives/representatives have sufficient information concerning the home and the services it offers and enables them to visit and assess the home prior to admission. The home has a relaxed and homely atmosphere and service users have the opportunity to engage in-group and individual interests and events, whilst the routines of the day are reasonable. The homes environment is well maintained and offers service users a pleasant standard of accommodation. Staff is committed and caring, whilst the Manager has twenty-one years experience of running the home.

What has improved since the last inspection?

There are medication policies and procedures for medication management. A system has been put in place to record the disposal of medication. A record is kept of the complaints received and how they have been dealt with. Fire doors now have fitted with alarm-activated doorstops. A risk assessment is in place for the service user who has been known to put them at risk when they open or close their bedroom window. The CSCI have been notified of matters described in Regulation 37 as and when it occurs.

What the care home could do better:

There are still some areas in relation to medication procedures in the home, which need to be addressed. That the home must implement a robust system for monitoring medication storage and administration procedures to ensure the home is able to evidence a suitable approach to regularly reviewing it`s medication practices. That there are clear guidelines for medicines prescribed on a `when required` basis that describes what this means for each individual service user. Changes to service user`s medication must be amended and recorded accurately in their care plans including dates and reasons for such changes. All records of administration must be maintained accurately at all times. Stocks of medication should be managed so that there is an adequate supply of medication and the service user is not left with no medication and awaiting a further supply to be delivered. The recruitment process followed should be clearly evidenced. Staff must not be allowed to working the home prior to gaining confirmation of the required Criminal Record Bureau (CRB)/POVA checks and where staff from overseas are working in the home evidence of checks carried out should be available to view. Further guidance should be should where moving and handling issues have been identified and an appropriate risk assessment carried out and recorded.

CARE HOMES FOR OLDER PEOPLE Thornbury Residential Home Hempstead Road Uckfield East Sussex TN22 1DT Lead Inspector Judy Gossedge Key Unannounced Inspection 30th May 2007 11:15 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 Residential Home DS0000021270.V338197.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 Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornbury Residential Home 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 admin@thornburyresidential.uwtadsi.co.uk thornburycare.co.uk Mrs Alyson Johnson Mr John 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 Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 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 25th October 2006 Brief Description of the Service: Thornbury is a residential care home providing personal care and accommodation for nineteen older people, being situated in walking distance from the town centre of Uckfield. The registered proprietor has owned and managed the home for over twenty-one 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, five of which have en-suite toilet 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 of the building; both the garden and patio areas allow easy access for service users. The home is attractively decorated and communal areas comprise of a conservatory leading off from the large main lounge with a separate dining room. The home has three communal bathrooms with assisted bathing facilities and three toilets. At the time of Inspection the accommodation fees at the home range from £400 to £450, with additional costs required for personal toiletries, newspapers and hairdressing. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An additional visit was made to by the Link Inspector and a Pharmacy Inspector to Thornbury on 25 October 2006 to monitor compliance with the requirements following the last inspection of 20 April 2006. Of concern was the fact that a number of requirements remained outstanding from the previous inspection and additional Requirements were made in relation to medication and recruitment procedures in the home. Following this a satisfactory response was received from the provider as to how these issues would be addressed. This unannounced inspection took place over seven and a quarter hours on 30 May 2007. Prior to the inspection an Annual Quality Assurance Assessment was sent to the home, which has been completed and returned and information detailed within is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms, rotas and care records were inspected. Fourteen service users were resident and five were spoken with either individually in their bedroom or generally in the communal areas. For four service users the care they had received during their stay was reviewed as part of the inspection process. The opportunity was also taken to observe the interaction between staff and service users in the communal areas. Ten service user surveys were sent out and eight came back completed. The Proprietor/Registered Manager, deputy manager, senior care worker, one care worker, the cook, a domestic/cook/care worker were all spoken with. Five relatives/visitors surveys were sent out and two completed surveys were returned and one further visitor was subsequently spoken with over the telephone. A member of the District Nursing team was subsequently spoken with over the telephone. What the service does well: Thornbury ensures that prospective service users and their relatives/representatives have sufficient information concerning the home and the services it offers and enables them to visit and assess the home prior to admission. The home has a relaxed and homely atmosphere and service users have the opportunity to engage in-group and individual interests and events, whilst the routines of the day are reasonable. The homes environment is well maintained and offers service users a pleasant standard of accommodation. Staff is committed and caring, whilst the Manager has twenty-one years experience of running the home. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 7 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 Residential Home DS0000021270.V338197.R01.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 Residential Home DS0000021270.V338197.R01.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 and 6 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential new service users are individually assessed prior to any admission to ensure that their care needs can be met in the home and there is information available about the home to inform service users and their representatives to enable an informed decision to be made prior to moving in to the home. EVIDENCE: The Statement of Purpose for the home outlines the service provided at Thornbury. The information details the length of time a service user can be accommodated for respite care. The Manager stated that a copy of the Service User’s Guide is given to new service users on admission and that this also contains a contract that includes terms and conditions of residency. The AQAA detailed that both these documents have been updated. A copy of the last Inspection report should also be fully accessible for service users and their representatives to read in the home. This was discussed with the Manager Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 10 who agreed to ensure this document was accessible. Feedback from service users and their representatives was varied but the majority felt they had received enough information about the home prior to moving in. The Manager stated that service users are visited prior to any admission. This is to ensure individual service user’s care needs can be met in the home and to provide staff with information on the care to be provided. For the one new service user admitted to the home since the last inspection the assessment information was viewed, which had been completed and supporting information from the service users previous home had also been provided. The AQAA detailed that prospective service users are invited to participate in the home as much as possible prior to an admission and the last service user admitted to the home was spoken with and who confirmed they had been able to visit the home prior to moving in. Intermediate care is not provided in the home. Thornbury Residential Home DS0000021270.V338197.R01.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 and 10. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have individual plans of care in place and personal care and support is provided in a way that maintains and respects the privacy, dignity and lifestyle of the service user, though the admissions process needs to ensure its completion along with supporting risk assessments. The current system of medicine storage and administration must continue to be improved to ensure that the medical needs of service users are not compromised or placed at risk. EVIDENCE: The AQAA detailed that there are policies in place to ensure that equality and diversity issues for individual service users are both identified and incorporated into service users individual plans of care. A selection of four of the service user’s individual care plans was viewed. The information detailed on three of the care plans demonstrated that the detail being recorded continues to be developed to give guidance to staff of the care to be provided, service user’s Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 12 personal and health care requirements, dietary needs, social and leisure interests and how any identified risks are to be managed. Service users are registered with local GP’s and records were viewed of health care appointments. Feedback from the service user surveys were varied stating they always, usually or sometimes received the medical support they need. One service user felt they would like more access to their GP. One relative survey stated that a GP or CPN has been called to their relative when necessary. The care plans viewed had been reviewed to ensure that this information is up-to-date and current care needs are being met. For the last admission to the home the information received as part of the inspection process had not been collated into a plan of care nor were supporting risk assessments in place. This was discussed with the Manager who stated she was unaware of this omission and that a care plan would be drafted with immediate effect, so a Requirement has not been made on this occasion. A number of supporting risk assessments were also viewed. Where service users go out from the home independently a risk assessment was not in place. Where one service user is transferred from bed to chair by a hoist a moving and handling risk assessment completed by a risk assessor had not been completed. This was discussed with the Manager to ensure that where moving and handling issues are identified appropriate guidance is sought, who stated this would be addressed with immediate effect. The staff team were observed during the inspection to ensure that the privacy and dignity of service users is respected. Feedback received of the care and support provided, observations and information detailed in service users individual care plans was that service users are enabled where possible to exercise choice whilst at Thornbury. The feedback from all the majority relatives and visitors was that they were happy with the overall care provided in the home. The AQAA detailed and staff stated that since the last inspection a great deal of work has been undertaken to resolve all the issues highlighted in relation to medication. Medication policies and procedures are in place and staffadministering medication has received medication training. Staff spoken with confirmed they had received training and that there is now a named worker responsible for the administration of medication each day. The Manager stated a pharmacist regularly visits the home, but the records of these visits were not viewed during the inspection. The storage and a sample of the recording of the administration of medication were also viewed and again there were a number of omissions of the recording of medication administered on the Medicine Administration Record (MAR) charts. Not all staff is using the same codes for recording medication administration. For two service users where medication was being administered, ‘as and when required’ there was no written guidance for one service user for guidance to staff as to when this should be administered. For another service user where the dosage of the medication administered had changed this had not been verified and dated. One service user had run out of their medication, which arrived during the Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 13 Inspection. The Manager has subsequently stated she has liaised with local practitioners to ensure systems are in place to resolve this issue. The home must implement a robust system for monitoring medication storage and administration procedures to ensure the home is able to evidence a suitable approach to regularly reviewing it’s medication practices. Thornbury Residential Home DS0000021270.V338197.R01.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 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Where possible service users are enabled to exercise choice in their lives whilst resident in the home, there are opportunities to participate in social and recreational activities provided, service users are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: The AQAA details an activities’ co-ordinator works in the home three mornings a week, who works with service users on one-to-one activities eg discussing newspaper articles, jigsaw puzzles, dominoes etc and group activities. That every Monday morning there is a music session which explores all music styles with a sing-a-long and then an exercise to music session. Alternate Fridays an external entertainer visits with quizzes, activities, exercise etc and in addition a further entertainers come to the home each week - a different one each time over a month, including sing-a-long kareoke, yoga, a musical entertainment duo, reminiscent therapy and on occasion a magician. During the morning of the Inspection the activities co-ordinator organised an exercise group and then Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 15 a card game. Two service users had also gone out to a local stroke club. The majority of service users surveys stated there are always or usually activities arranged, some service users indicated they preferred their own activities and some comments were received that more activities would be welcomed. All the relatives/visitors confirmed there was flexible visiting, that staff are very welcoming and they could see their relative/friend in private if they wished. A comment received, ’the staff are always welcoming and friendly and have a great sense of humour and fun.’ The care and support provided was observed to enable service users where possible to exercise choice whilst at Thornbury. The three service user files viewed confirmed this. The cook working on the day stated she held a basic food hygiene certificate and is working towards the advanced hygeine certificate. A second cook was also spoken with who stated she held a basic food hygiene but had not had an update since 1997, but that the Manager had already raised this with her and was she was due to complete an update shortly. A new menu is devised every five weeks, which staff stated takes into account service users likes and dislikes. Special diets are catered for and the AQAA detailed that further advice/guidance had been sought for the main cook in the home with an NHS dietician. The lunchtime meal was served in the dining room and staff were observed to be available to offer any assistance to service users if required. Lunch was roast lamb, roast potatoes, fresh spinach, broccoli, swede and parsnip followed by fruit sponge and custard. The AQAA detailed that organic fruit and vegetable are purchased for the home. Records are kept of individual food consumption to ensure service users have had an adequate diet. All the service users surveys stated they always or usually liked the meals. One commented, ‘ very good.’ Service users spoken with on the day all spoke well of the food. The care and support provided was observed to enable service users where possible to exercise choice whilst at Thornbury. The three service user files viewed including the five service users whose care was reveiwed confirmed this. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse, but it must be ensured that any concerns or complaints are addressed appropriately EVIDENCE: There is a complaints policy and procedure in place a copy of which is displayed in a communal area of the home. The complaints book was viewed and detailed that two complaints had been received at the home during the last year. The CSCI received one concern in relation to the care provided at Thornbury. Six of the of service user surveys stated that they know how to make a complaint and one did not. Three stated they always know who to speak to if they are unhappy and four stated they usually did. Not all the relatives/visitor stated they were aware of the complaints procedure, but knew who to talk to if they had any concerns. At the last Inspection the Manager noted that she often takes any complaints, concerns or allegations ‘personally’ and acknowledged that this can Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 17 occasionally lead to her initially responding to those expressing such issues in a defensive manner and accepted that she is endeavouring to address future situations in a more objective fashion. The importance and benefit of looking at any issues raised in an objective manner was discussed again with the Manager. The AQAA detailed that there are policies and procedures in place in relation to the protection of vulnerable adults and two care workers spoken with confirmed an awareness of the policies and procedures. The Manager stated and evidenced information had been received which it is proposed will used to provide further guidance/update to staff. See Standard 29 in relation to recruitment checks. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is decorated and furnished in a homely style. A maintenance plan has been put in place to ensure that the standard of the environment continues to be improved so that service users are provided with an attractive, safe and homely place to live. EVIDENCE: The AQAA details that there is a maintenance plan in place for the home and detailed that various rooms have been decorated in the last twelve months, a Victorian fireplace uncovered in one of the communal areas and plans to provide a summerhouse in the garden, the preparatory work being viewed during the Inspection. A tour of the building was made. The home is decorated and furnished in a homely style. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 19 There is not a passenger lift in the home, but a stair lift is available to service users unable to use the stairs to the first floor. There are sixteen single bedrooms of which the AQAA details five do not meet the minimum space requirements, situated on both floors in the home. A selection of bedrooms were viewed and these were found to be clean, well maintained and it was noted there had been a lot of effort to individualise the rooms by service users with personal items such as photographs, pictures, ornaments and some furniture. The AQAA details that an emergency call system is fitted throughout the home. Service users are able to control the temperature in their own bedrooms. Where asked service user confirmed an adequate supply of hot water. The Manager stated that there are regular checks of the recording of the testing of the hot water temperature, but it could not be found during the Inspection, so it was not possible to evidence if hot water at outlets accessed by service users is being maintained at close to 43 º C. The Manager stated that the record would be found and maintained so a Requirement was not left on this occasion. The AQAA details that five bedrooms have en-suite facilities with a further three communal bathrooms with assisted bathing facilities provided throughout the home. There is a lounge, conservatory and dining room on the ground floor. There is a garden at the front of the home. The AQAA details that there is a policy in place for managing infection control. The home was found to be clean, tidy, and free from offensive odours or smells. Feedback from relatives and visitors to the home was that the home was always fresh and clean. Recording was viewed of routine fire checks that had been carried out in the home. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 20 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 and 30. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A robust recruitment procedure needs to be in place to ensure service users are in safe hands at all times. Care workers are being provided with training to ensure they can meet the care needs of the service users. EVIDENCE: The staff rota was viewed and staff spoken with confirmed that there is usually a minimum of three care workers on duty during the day. During the Inspection only two care workers were on duty during the day. The Manager stated this was due to the absence of two members of staff to have been working in the home, who had not been replaced due to the lower occupancy in the home and the Manager and deputy manager were working in the home during the day. Ancillary staff was working in the home covering catering and domestic duties. Since the last Inspection a staff-sleep in room has been created and the AQAA detailed that there is now a waking member of staff on at night and a sleeping-in night duty. On the night of the Inspection again the sleeping-in member of staff was absent and the Manager stated they had been unable to cover this shift and so had made arrangements for one of the day Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 21 care workers to work longer to support the night care worker in assisting service users to bed. Standard 28 has not been met as fifty percent of the staff have not achieved NVQ level 2 or equivalent in care. But the Manager stated that nine of the twenty-one care workers hold NVQ Level 2 or above, one is awaiting verification following completion of the course and six further members of staff are working towards the qualification. The recruitment process followed was viewed for the three new members of care staff all of whom had been recruited since the last inspection. The records viewed evidenced the completion of an application form, that two references are sought, although it was not possible to evidence when these references had been received and in all cases who had written the reference and all had a completed a CRB/POVA First check. In one instance the member of staff had commenced working in the home prior to a POVA First check having been received. Where staff from overseas have been employed it was not possible to evidence the required checks had been carried out. This was discussed the Manager during the Inspection who stated she has taken further advice and is satisfied that staff employed from overseas to work in the home have the required checks carried out prior to commencing employment. Recruitment records held need to clearly evidence the recruitment process which has been followed. The Manager had stated that induction training to meet the requirements of the General Skills for Care induction standards and evidenced that one new member of care staff is currently going through the induction process. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 22 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. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Manager conveys a wealth of relevant experience and knowledge. Quality assurance systems have been developed to enable ongoing feedback about the care provided in the home and systems are in place to ensure a safe environment for staff and service users. EVIDENCE: The Provider/Registered Manager for the home has been providing a residential care service for older people at the home for over twenty one years and stated she is completing a Certificate in Management course, which had been expected to be completed by the end of 2006 and is now due to be completed by the end of summer 2007. There is a deputy manager to support the Manager. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 23 The AQAA details that quality assurance and monitoring system is in place. The Registered Manager stated a survey for 2007 is in process with feedback being sought from service users, relatives and other stakeholders. Service users are also able to comment at residents meetings, although the Manager stated a meeting was overdue and it was discussed the importance of maintaining this forum for service users. Currently feedback had not been collated and available to be viewed. This was discussed with the Manager who confirmed this information would be collated and made available to be read as required. The AQAA detailed that policies and procedures are in place, but these would benefit from a more regular review. The home is not involved in the management of any of the personal finances of service users. The AQAA details that each member of staff is met formally six times a year for supervision and the two care workers spoken with confirmed this and that there are staff meetings. Training records were viewed, but were not up-to-date so it was possible to evidence if all staff had received training in moving and handling, basic food hygiene, first aid and infection control within the required timescales. This was discussed with the Manager who stated she was working on updating the records so a requirement has not been made on this occasion. Moving and handling training was also discussed to ensure that this meets with current requirements. The Manager subsequently confirmed that further training is being sought to address this issue. The two care workers spoken with did confirm attendance at all the required training. The AQAA detailed that the maintenance of equipment and services has been carried out. The Manager stated that she had commissioned an external agency to complete a fire risk assessment for the home and evidenced regular fire and environmental checks of the building. Records evidenced that staff attended fire training and there are also fire drills facilitated in the home and the staff spoken with confirmed attendance at this training. A system is in place for informing then CSCI of reportable matters. Recording was viewed of incidents and accidents, which had occurred in the home. Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 24 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 13 (4) (b) (c) 13(2) Requirement That where service users are going out of the home independently a risk assessment is completed. That the home must have clear guidelines for medicines prescribed on a ‘when required’ basis that clearly describes what this means for each individual service user. This issue is outstanding since 31/05/06 and 25/11/06. That all records of administration must be maintained accurately at all times. This issue is outstanding since 25/10/6 That any changes to a service users medication must be amended and recorded accurately in their care plans including dates and reasons for such changes. This issue is outstanding since 25/11/06 That all medication must be stock controlled via written records including medication not DS0000021270.V338197.R01.S.doc Timescale for action 31/07/07 2. OP9 31/07/07 3. OP9 13(2) 31/07/07 4. OP9 13(2) 31/07/07 5. OP9 13(2) 31/07/07 Thornbury Residential Home Version 5.2 Page 26 available in blister packs to ensure service users are receiving the medication they require. This issue is outstanding since 25/11/06 6. OP29 19(1)(b) That the Manager must not allow staff to work at the home prior to gaining confirmation of the required CRB checks being completed. This issue is outstanding since 15/11/06 That moving and handling risk assessments will be completed where required. 30/07/07 7. OP38 13 (5) 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thornbury Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Residential Home DS0000021270.V338197.R01.S.doc Version 5.2 Page 28 - 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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