Inspection on 13/10/05 for Thorncliffe

This inspection was carried out on 13th October 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

Thorncliffe 05/07/06

Thorncliffe 13/02/06

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 October 2005 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.V258249.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. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 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.V258249.R01.S.doc Version 5.0 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 8th February 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.V258249.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out on one day, over a period of six hours. The registered person, who is also the manager, was available throughout the inspection. In addition to care staff, the home employs a maintenance person, housekeepers and catering staff. The case files and care plans examined as part of the inspection concerned a newly admitted person, a person whose needs had changed, a person with a diagnosis of dementia and a person who had lived at the home for a long time. Two residents described their experiences of the service they receive. The inspector also spoke with a group of residents and observed care practices. A student on placement at Thorncliffe also assisted with the inspection by describing her experience during her placement. Ten comment cards were received from the residents; they contained no adverse comments and confirmed, without exception, their satisfaction of all aspect of the service. Requirements made at previous inspections were also checked for compliance. What the service does well: What has improved since the last inspection? Some care practices, specifically those carried out during the morning and evenings, have been reviewed to provide a better individual service. A programme of redecoration and refurnishing has been carried out in the communal areas and some bedrooms. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 6 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.V258249.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 Thorncliffe DS0000005590.V258249.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): 3&5 Systems are in place to ensure the residents’ needs can be fully identified and met by the home. Prospective residents and their representatives have the opportunity to visit the home and have a meal before making a decision to move in. EVIDENCE: Care needs assessments were contained within the four care files examined as part of the inspection. The home also has a process of assessing potential residents’ needs carried out by a senior member of staff. By completing such an assessment, the home can ascertain individual needs and ensure they can be met. The manager confirmed that, wherever possible, prospective residents and their representatives are offered the opportunity to look around the home and can be invited to join the residents for a meal. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 9 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, 8, 9 & 10 The residents’ personal care, health and welfare needs are fully documented and met by the various healthcare professionals and through the provision of specialist equipment. The residents are enabled to self medicate wherever possible. The residents are treated with respect and their privacy is maintained at all times. EVIDENCE: Four care plans were examined as part of the inspection process. They clearly set out the residents’ individual care needs. The care plans document the action to be taken by the carers to ensure all aspects of health, personal and social care are met and reviewed. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 10 Where identified, the resident’s health is monitored and addressed by the appropriate health care professionals. The district nurses are involved on a regular basis as are the chiropodist, audiologist and optician. Specialist equipment to prevent pressure sores was in evidence; this is provided after an assessment of need by the district nurse. Four medication administration records were examined and found to be completed in the approved manner. All senior staff responsible for the administration of medication have received the appropriate training. Records are retained to show changes to medications. There is a policy and procedure in place to enable the residents to self medicate where this is considered to be appropriate and subject to an assessment of risk. It was noted that none of the current residents were considered able to self medicate. The inspector observed the staff respecting the residents’ privacy by knocking and waiting before entering the room. All the rooms are provided with locks. It was particularly noticeable that the carers spoke with the residents in a respectful manner. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 11 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, 14 & 15 The residents’ previous lifestyles and social histories are briefly documented. The choices offered to the residents meet with their requirements and needs. The residents are able to exercise control over their lives through residents’ meetings. Visitors are made to feel welcome and remain in contact with their relatives’ care. The contents of the menu appeared nutritious and well balanced with a choice provided at each mealtime. EVIDENCE: The individual care plans briefly document the resident’s previous lifestyle and social history. The carers clearly demonstrated their knowledge of the residents’ previous experiences and fully understood the importance of this in providing the care package. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 12 The residents’ families and friends are welcome at all times. They are also invited to become involved in activities and trips. Their support is considered to be an integral part of the individuals’ care. Activities include trips out to the local pub for lunch and themed days with appropriate food and decorations. The Christmas party was being arranged and entertainers visit the home at regular intervals. There is an informal atmosphere at Thorncliffe with a good level of interactions between the residents and carers. A recent change to the breakfast routine had been carried out. The residents’ views had been obtained regarding the changes that involve serving the meal with music of the residents’ choice. The main meal of the day at the home is served at 1.00pm; the evening meal is provided at 5pm with supper from 7.30pm. The residents’ likes, dislikes and dietary requirements are documented and made known to the cook. It was apparent from the clean plates that the main meal had been well received. The meal choices for the day were clearly displayed close to the dining room. The residents who spoke with the inspector were unable to remember what they had chosen for their next meal. The menu for the week was examined, it appeared to be nutritious and well balanced. The residents at the home are involved in changing the content. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed at this time. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 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, 20, 23 & 26 Thorncliffe provides a warm, clean and well-maintained environment with a good standard of furnishings and fittings. The residents’ accommodation meets fully with their identified needs. EVIDENCE: A tour of the home was carried out and all areas were found to be clean and pleasant. Some furnishing had been replaced in the main lounge and new curtains had been ordered. The bedrooms had been nicely personalised and it was apparent that the residents had access to them throughout the day. The residents’ comment cards noted they were satisfied with the standard of accommodation. All the furnishings and decoration were to a good standard and gave a homely feel. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 15 A dedicated worker carries out all the maintenance of the building and grounds. The main entrance into the home is via the front door that is opened by staff. Visitors are encouraged to sign in and out to comply with the health and safety regulations. The rear garden is fully accessible and secure. It is a pleasant area, complete with garden furniture. Some bedrooms overlook the garden. Thorncliffe is maintained in a clean and hygienic state; there were no offensive smells noted. The residents commented that this was the usual state in the home. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 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, 28, 29 & 30 The home employs staff in numbers to meet the assessed needs of the residents, who receive care from well-trained staff who respond in a respectful manner. The organisation’s recruitment policy and procedure provide protection to the residents from potential abuse. EVIDENCE: There is a good balance of workers with age and experience, adequate in numbers to meet the assessed needs of the residents. At the time of the inspection a student was on work placement and she confirmed she had been made welcome by the staff and had been supervised by an experienced worker throughout. 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 carers have attended training courses with the attendance certificates displayed in the hallway. A total of four carers have achieved level 2 National Vocational Qualification (or equivalent). The manager is committed to the NVQ system and confirmed that the majority of carers were enrolled and working towards completion at level 2. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 17 A selection of staff files was examined. They contained the required references, application forms and CRB clearances to ensure the residents’ safety. The files are retained in a secure manner. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 18 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 & 38 The manager has the experience and skills to run the home but has yet to achieve the Registered Manager’s Award. 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 Manager’s 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.V258249.R01.S.doc Version 5.0 Page 19 The staff have received the mandatory training in health and safety; first aid; fire awareness and food and hygiene. The maintenance of all appliances and equipment is carried out under contract. The health, safety and welfare is further ensured by the systems in place to report accident and incidents. Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 20 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X 17 X 18 X 3 3 X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X X X 3 Thorncliffe DS0000005590.V258249.R01.S.doc Version 5.0 Page 21 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 OP31 Regulation Requirement Timescale for action 01/06/06 9(1)(2)(b) The registered person must complete a National Vocational Qualification at level 4 (Registered Manager’s Award) (Previous timescale of 01/04/05 not met). 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.V258249.R01.S.doc Version 5.0 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.V258249.R01.S.doc Version 5.0 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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