Inspection on 05/07/06 for Thorncliffe

This inspection was carried out on 5th July 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 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 13/02/06

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 5th July 2006 11:00 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 Thorncliffe DS0000005590.V301763.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. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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.V301763.R01.S.doc Version 5.2 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 February 2006 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. Fees for accommodation and care at the home range from £315.77 to £271.74 per week. Additional charges are made for hairdressing and chiropody services, newspapers and personal toiletries. Details of the facilities provided by the home are contained in the service user guide, which is displayed in the entrance hall. 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.V301763.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection which included an unannounced site visit to the home. 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 process of inspection included the examination of case files and care plans concerning 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. Other records required by legislation were also examined. Requirements made at previous inspections were also checked for compliance. Two residents described their experiences of the service they receive. The inspector also spoke with relatives who were visiting the home during both days of the inspection. Carers and a housekeeper were also interviewed and care practice was observed. A visiting mental health worker spoke with the inspector and confirmed the good professional working relationship they enjoy with the staff of Thorncliffe. What the service does well: Thorncliffe provides a warm, relaxed and comfortable environment where the residents can be themselves. The home is well maintained, clean and hygienic and furnished in a homely style. The residents of Thorncliffe enjoy a variety of trips to the local pub for lunch, entertainers who visit the home at regular intervals and regular armchair aerobics. The manager is mindful of the frailer residents’ needs and tailors the trips out to reflect their abilities. There is an informal atmosphere, with plenty of banter and conversation between the residents and the staff. The visitors welcomed the informality, stating it made them feel relaxed and at home. Many of the staff are related to each other and have worked at the home for years, which may help to create the relaxed attitude and manner towards the caring task. In the main, good systems and recording methods are in place to ensure the residents receive care to meet their assessed needs at all times. The staff work well together as a team providing informal and unhurried care. Thorncliffe DS0000005590.V301763.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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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.V301763.R01.S.doc Version 5.2 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 quality rating in this outcome area is good. Systems are in place to ensure the residents’ needs can be fully identified and met by the home. Intermediate care is not provided at Thorncliffe (standard 6). This judgement has been made using available evidence, including a visit to the service. EVIDENCE: At the previous inspection there was a requirement to ensure prospective residents have a full assessment for care needs prior to being admitted to the home. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 Page 9 As part of the inspection process, the inspector examined four care files, including a recently admitted resident. It was noted that a full assessment of needs had been completed by the social worker and the home had also carried out their own process. The documentation was appropriate to the resident’s needs and there was evidence of their involvement. The needs of the principal carer and next of kin were also documented. A visitor described to the inspector the process that had taken place prior to his relative being admitted to the home. He confirmed he and his relative had had the opportunity to look at two homes before deciding that Thorncliffe would meet their needs. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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, 8, 9 & 10 The quality rating in this outcome area is good. The residents’ health and personal care needs are generally well met, however, in one instance, not reflected in the documentation. This oversight could result in carers being inconsistent in their approach. This judgement has been made using available evidence, including a visit to the service. 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. There was some evidence of the resident being involved in the process, although in discussion the residents were unable to recall their care needs. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 Page 11 Risk assessments were in place, although it was noted in one instance that carers were providing appropriate and satisfactory care to a resident but the risk assessments failed to reflect their good practice. It was apparent that the resident had received injuries to both arms and her face as a result of two separate falls. The incidents had been documented, and reported in the accident book. The manager had also put a mechanism in place to alert the night staff in the event of her getting out of bed unassisted but had failed to update the risk assessment and report the accidents to the Commission for Social Care Inspection according to regulation 37. Other risk assessments were in place and were appropriate to the care provided. A resident collapsed during the inspection. The manager assessed her as requiring attention at the accident and emergency unit. The resident was taken by ambulance with a carer escorting and reassuring her, the family were also informed. The whole incident was dealt with calmly and with minimal fuss. Where identified, the residents’ 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. A mental health worker, who was visiting the home to review her client’s needs, spoke with the inspector. She was impressed with the care provided by the home and, in particular, to her client who had recently been admitted. The home was highly thought of by the mental health team for the informal care the staff provide. 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. The inspector observed the staff respecting the residents’ privacy by knocking and waiting before entering the room. It was particularly noticeable that the carers spoke with the residents in a respectful manner. Those residents who spoke with the inspector confirmed they felt safe, particularly at night. One person said they had to follow a special (medical) diet as a result of diabetes; this was being satisfactorily addressed by the carers and the cooks. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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, 14 & 15 The quality rating in this outcome area good. The residents benefit from attending various events in the local community and are kept up to date through themed days held at the home. Visitors are encouraged to remain in contact and are made to feel welcome at the home, ensuring residents remain in touch with their family and friends. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: The individual care plans briefly document the residents’ 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. 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. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 Page 13 Four visitors were interviewed during the inspection. They all spoke very highly of the staff and the care provided to their relative. One person said he was told that he would continue to be involved in his relative’s care, a comment that made him feel reassured. He had taken his relative back home for a meal and other relatives were preparing to take her out for lunch. They all confirmed they were pleasantly surprised at the informality in the home and felt at ease with the situation. They visited at all times during the day and were provided with light refreshments. Activities include trips out to the local pub for lunch and themed days, with appropriate food and decorations. A recent trip to the town hall for a special evening with entertainment was enjoyed. At interview carers described playing dominoes and beauty therapy for the ladies. One carer said she was aware that a resident had enjoyed walking so she walked with her to the local school to pick her child up. There is an informal atmosphere at Thorncliffe with a good level of banter between the residents and carers. The meal choices for the day were clearly displayed on a chalkboard close to the dining room. The residents who spoke with the inspector were unable to remember what they had chosen for their next meal, but confirmed that the food was “very good.” 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 menu for the week was examined; it appeared to be nutritious and well balanced. A visiting mental health worker was particularly impressed by the care and attention given to the place settings and the general ambience in the dining room. At the time of the inspection the majority of the residents were sitting in the garden enjoying a lunchtime barbeque. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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 & 18 The quality rating in this outcome area good. Systems are in place to ensure the residents are protected from abuse and the staff have received the appropriate training to make them aware of potential abusive situations. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: Thorncliffe has a complaints procedure and records any complaints made. The procedure is available to the residents and their representatives within the service user guide. Relatives confirmed they had seen the procedure and felt assured the manager would treat their concerns seriously. They stated that they had been encouraged to speak to the staff if they had any concerns. Those residents who spoke with the inspector said they had not made a complaint. They were unsure of any process but said they would speak to a member of staff. One resident said she would speak to her son if she was unhappy. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 Page 15 Formal training has been arranged through the local authority to provide the carers with required information concerning the protection of vulnerable adults. The carers confirmed to the inspector they had received this training. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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 & 26 The quality rating in this outcome area is good Thorncliffe provides a warm, clean and well-maintained environment, with a good standard of furnishings and fittings. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: A short tour of the home was carried out. The home was found to be clean and hygienic. It is the home’s policy to redecorate vacant rooms with the prospective resident’s own choice of colours. The bedrooms had also been nicely personalised and it was apparent that the residents had access to them throughout the day. All the furnishings and decoration were to a good standard and gave a homely feel. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 Page 17 A dedicated worker carries out all the maintenance of the building and grounds. The main entrance into the home is via the front door. 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 and parasols. A small group of residents were enjoying the sunny weather during the inspection. Thorncliffe is maintained in a clean and hygienic state; there were no offensive smells noted. The residents and visitors commented that this was the usual state in the home. A resident said they were very satisfied with their accommodation and particularly liked the furniture in the bedroom. This person had her family visiting her and they to stated they were happy with the home and the general environment. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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, 28, 29 & 30 The quality rating in this outcome area is good. The home employs staff in numbers to meet the assessed needs of the residents. The residents receive care from a well trained team who respond in a respectful and timely manner. The home’s recruitment policy and procedure provide protection to the residents from potential abuse. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: There is a good balance of workers in age and experience, adequate in numbers to meet the assessed needs of the residents in a relaxed manner. 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. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 Page 19 The carers have attended training courses with the attendance certificates displayed in the hallway. The manager is committed to the National Vocational Qualification system and confirmed that the majority of carers had achieved level 2 and the rest were enrolled and working towards completion at level 2. A carer spoke to the inspector about her experience of the course and confirmed all mandatory training completed. It was explained that the manager also works alongside the carers, thereby ensuring the quality of care meets with her standards. Visitors valued the fact that there was always a senior member of staff available to speak with them should the need arise. 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. The residents and visitors who spoke with the inspector stated they were satisfied with the numbers of staff on duty at any one time. One resident said she felt safe and had made friends with other residents. A further resident said she knew there were carers working during the night, as they had brought her a hot drink when she was unable to sleep. This person said the staff made her feel “safe and secure.” Those staff who spoke with the inspector all stated they enjoyed working at the home. They said they all get on well together and stated they are proud of the home and the people who live there. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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, 33, 35 & 38 The quality rating in this outcome area is good. The systems and procedures in place are consistently monitored by the manager, ensuring the residents’ best interests are promoted and protected. This judgement has been made using available evidence, including a visit to the service. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 Page 21 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 previous inspections there have been requirements 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. It is anticipated the course will commence in September 2006. The manager has a system of reviewing the home’s 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 residents’ relatives and visitors stated that they were kept informed and consulted on any important matters. The home is working towards the Investor in People Award. Small amounts of monies are retained for safekeeping 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. 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 are further ensured by the systems in place to report accident and incidents, however the registered person has failed to report incidents and accidents, as required, to the Commission for Social Care Inspection. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 17 X 18 3 3 X X X X 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 2 X 3 X 3 X X 2 Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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 OP7 Regulation 13(4)(c) Requirement Timescale for action 10/08/06 2 OP31 3 OP38 The registered person must ensure all risks are identified and documented, and risk assessments reviewed as necessary. 9(1)(2)(b) The registered person must have 01/10/07 achieved a National Vocational Qualification at level 4 (Registered Manager’s Award) (Previous timescales 01/04/05 & 01/06/06 not met). 37 The registered person must 10/08/06 ensure all accidents and incidents are reported to the Commission for Social Care Inspection within 24 hours of occurrence. Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 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. Refer to Standard Good Practice Recommendations Thorncliffe DS0000005590.V301763.R01.S.doc Version 5.2 Page 25 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.V301763.R01.S.doc Version 5.2 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!