Inspection on 13/02/06 for Thorncliffe

This inspection was carried out on 13th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Thorncliffe 05/07/06

Thorncliffe 13/10/05

Thorncliffe 08/02/05

Thorncliffe 07/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Thorncliffe Crescent Road Dukinfield Tameside SK16 4EY Lead Inspector Janet Ranson Unannounced Inspection 13th February 2006 09:30 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 Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 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. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thorncliffe Address Crescent Road Dukinfield Tameside SK16 4EY 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) 0161 339 7055 NO FAX Mrs Marilyn Ann Norton Mrs Marilyn Ann Norton Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (15), of places Physical disability over 65 years of age (8) Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 15 OP, up to 15 DE (E),up to 8 PD (E). Date of last inspection 13th October 2005 Brief Description of the Service: Thorncliffe is a large, detached building that has been extended and adapted to meet the needs of 15 older people, some of whom will have physical disability or dementia. The accommodation is provided on two floors. There are 11 single and two shared bedrooms, none of which have en-suite facilities. On the ground floor there are two lounges, a conservatory and one dining room. Adapted toilets and bathrooms are available close to the communal rooms and private accommodation. There is an enclosed garden to the rear of the property, accessible from the conservatory. Car parking is to the front of the building. The home is located on a bus route close to the centre of Ashton. Off road parking is provided at the front of the house. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over a period of three and a half hours. The registered person who is also the manager was off duty at the time of the inspection, which was professionally carried out by a senior carer. In addition to care staff, the home employs a maintenance person, housekeepers and catering staff. A case file and care plan concerned a newly admitted person was examined as part of the inspection process. This person also described their experience of the service they receive at the home. The inspector also spoke with a group of residents; observed care practices, toured the building and spoke informally to the staff group. Seven out of ten comment cards, left after the previous inspection in October 2005, were received from relatives or visitors residents. With out exception they stated they were kept informed of important matters and consulted about their relative’s care (where this was appropriate). Four stated they were not aware of the home’s complaints procedure but none of the respondents said they had had to make a complaint regarding the service. Written comments were also received; “Thorncliffe staff are excellent they look after everybody with love and care. The cleanliness, food etc. is of a high standard and I am very happy with my relatives care.” “My family and I think the standard of care, cleanliness etc is of a very high standard.” “(My relative) has only been at Thorncliffe a short time but I heard very good reports from people who had someone staying or had stayed. (My relative) seems very happy here which makes us happy.” A requirement made at the previous inspection was also checked for compliance. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 6 What the service does well: 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 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 Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 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): 3&5 The staff are providing appropriate and satisfactory care but in one instance, the records failed to reflect the good practice. Standard 6 (intermediate care) is not provided at Thorncliffe. EVIDENCE: The inspector examined a care file that had been set up for a person who had been admitted to the home earlier in the week. It was disappointing to note only the very basic personal details had been documented and no care plan had been devised. This was due (in part) to the lack of background information or written assessment from either the social worker or from the home. It is understood that the prospective resident had previously spent a day at the home (having lunch and tea) and giving the senior staff the opportunity to make an assessment of need. This is considered to be good practice however the assessment had not been documented and the person had been admitted to the home within a short period of time. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 9 The inspector spoke at length to the resident who appeared unable to understand her surroundings and was disorientated in time. It was apparent from her reaction to the staff that she felt comfortable in their company. The senior carer stated that the social worker had been reminded to send the required information as quickly as possible. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 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 With one exception, the resident’s personal care health and welfare needs are fully documented and reviewed. Standards 8 and 10 were inspected during the previous unannounced inspection (October 2005) when they were judged to meet fully with the intended outcomes. EVIDENCE: As reported in standard 3 a person had been recently admitted into Thorncliffe with no written assessment of need. Further to this there was no care plan documenting how the resident’s identified needs were to be met. The staff were caring for this person in an intuitive manner and observations concerning the resident’s demeanour and sleeping pattern etc. had been documented. It was noted that a change had been made to the resident’s general practitioner (GP). Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 11 The Medical Administration Record (MAR) sheet for the newly admitted resident was examined and found to be completed in the approved manner. The prescription had also been reviewed by the resident’s new GP at the request of the manager of the home. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 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): Standards 12,13,14, and 15 were inspected at the previous unannounced inspection (October 2005) when they were judged to meet fully with the intended outcomes. EVIDENCE: A small group of residents and staff described the Christmas activities that included a meal at the local pub and the arrangements for a birthday party to be carried out the day after the inspection. During the inspection a carer was observed to be manicuring and painting a resident’s nails all the while chatting with the other residents. This is indicative of the homes relaxed and informal approach to caring for people. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 13 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 & 18 Systems are in place to ensure the resident’s are protected from abuse and the staff have received the appropriate training to make them aware of potential abusive situations. EVIDENCE: Three respondents noted on the comment card that they were not aware of the home’s complaints procedure. Four confirmed they did know of the procedure. All seven wrote they had not had occasion to make a complaint to the home. Thorncliffe does have a complaints procedure and records of any complaints made to them. The procedure is available to the resident’s and their representatives within the service users guide. The manager should take note of the relative’s comments and ensure the complaints procedure is brought to their attention. Formal training has been arranged through the local authority to provide the carers with required information concerning the protection of vulnerable adults. It is anticipated that all the carers will receive this training. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 14 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, 24 & 26 Thorncliffe provides a warm, clean, and well-maintained environment with a good standard of furnishings and fittings. EVIDENCE: The home employs a person who deals with the day-to-day maintenance requirements. At the time of the inspection problems concerning the water pressures were being addressed. No other issues of outstanding maintenance were noted during a tour of the building. It is the homes policy to redecorate vacant rooms with the prospective resident’s own choice of colours. This is very considerate and in addition to the resident’s own effects (pictures, ornaments, photographs etc) must enable the occupant to recognise their surroundings. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 15 Thorncliffe is maintained in a very clean and hygienic state by a team of housekeepers. This was also confirmed within the relatives/visitors comment cards. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 16 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 & 30 The home employs staff in numbers and with the appropriate skills to meet the assessed needs of the residents. Standards 28 and 29 were assessed at the previous unannounced inspection where they were judged to meet fully with the intended outcomes. EVIDENCE: There is a good balance of workers with age and experience, adequate in numbers to meet the assessed needs of the residents. The workforce is stable with very little turnover; this can only serve to provide a continuity of care and a level of security for the residents. The relatives responded in a positive manner to the numbers and skill mix of the staff at Thorncliffe. The registered person remains committed to the National Vocational Qualification (NVQ) system and it is understood that the majority of carers were enrolled and working towards completion at level 2. A newly employed carer understood that she was to be enrolled on the level 2 course. Some distance learning courses had been attended and a course concerning the care of the dying was also available. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 17 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, 33 & 35 Monitoring of systems and procedures ensure the resident’s best interests are promoted and protected. Standard 38 was assessed at the previous unannounced inspection (October 2005) where it was judged to meet fully with the intended outcome. EVIDENCE: The registered person, who is also the registered manager, is a qualified nurse and has had many years’ experience in caring for older people. She is involved on a day-to-day basis and can demonstrate periodic training to update her skills. At the last inspection there was a requirement that she must achieve the NVQ (Registered Managers Award) level 4. It is understood that the manager has experienced difficulties enrolling onto the course but has now managed to find a suitable training provider. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 18 The manager has a system of reviewing the homes policies and procedures at regular intervals. This is considered to be good practice. There was evidence to show that the individual care plans are also reviewed. The resident’s relatives and visitors wrote that they were kept informed and consulted on any important matters. Copies of the inspection reports were available close to the visitors signing in book in the hallway. Small amounts of monies are retained for safe keeping by the registered person. The money is made available to the home for small expenses, by the resident’s relative or representative, as the registered person has no involvement with the individual finances. All records of expenditure are retained for inspection, along with the receipts. The records were appropriately maintained in order that the financial interests of the residents were safeguarded. Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 19 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 X X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X X Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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) Requirement Timescale for action 01/04/06 2 OP7 3 OP31 The registered person must ensure they do not provide accommodation to a person unless the needs of the client have been assessed and a copy of the assessment has been obtained. 15(1) The registered person must 01/04/06 ensure a care plan is completed (in conjunction with the resident or their representative where ever possible), when the resident is admitted to the home. 9(1)(2)(b) The registered person must have 01/06/06 achieved a National Vocational Qualification at level 4 (Registered Manager’s Award) (Previous timescale 01/04/05 not met) Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 21 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 Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Thorncliffe DS0000005590.V278273.R01.S.doc Version 5.1 Page 23 - 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. 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