Inspection on 17/05/06 for Thorncliffe Grange Nursing Home

This inspection was carried out on 17th May 2006.

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 Grange Nursing Home 23/09/08

Thorncliffe Grange Nursing Home 04/10/07

Thorncliffe Grange Nursing Home 12/11/05

Thorncliffe Grange Nursing Home 25/04/05

Thorncliffe Grange Nursing Home 25/11/04

Thorncliffe Grange Nursing Home 19/05/04

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 Grange Nursing Home 2-4 Windmill Lane Denton Tameside M34 3RN Lead Inspector Mrs Fiona Bryan Announced Inspection 21.15p 18 May 2006 th 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 Grange Nursing Home DS0000043576.V292873.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 Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thorncliffe Grange Nursing Home Address 2-4 Windmill Lane Denton Tameside M34 3RN 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 320 0740 0161 320 7374 Partnership Caring Limited Julie Richardson Care Home 50 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (50), of places Physical disability (50), Physical disability over 65 years of age (50), Terminally ill (2) Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. No service user to be admitted into the home who is under 55 years of age. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The Manager must be supernumerary at all times. For up to 25 service users requiring nursing care 1 Registered Nurse to be on duty over each 24 hour period. For 26 - 50 service users requiring nursing care 2 Registered Nurses to be on duty over each 24 hour period. The home is registered for a maximum of 50 service users to include up to 15 DE(E), up to 50 OP, up to 50 PD, up to 50 PD(E) and up to 2 TI. 12th November 2005 Date of last inspection Brief Description of the Service: Thorncliffe Grange provides accommodation for up to 50 service users requiring personal and nursing care. The home is owned by a partnership and is under the control of a manager who is also a qualified nurse. Fees for accommodation and care at the home range from £323.66 to £440.75 per week. Additional charges are also made for hairdressing and chiropody services, newspapers and personal toiletries. The accommodation is within two converted Edwardian houses that are connected by a purpose built extension and link. The home retains many of the original features of both properties. Accommodation is provided over two floors. 22 of the bedrooms are single en-suite whilst a further 20 single rooms, without en-suite facilities, are provided with washbasins. Four rooms are double rooms, two being en-suite and two not. A large lounge with attached conservatory is provided on the ground floor with a small dining room also available. On the first floor service users can utilise a large lounge/dining room. The home is located off the main A57 in the town of Denton. It is on the main bus route and is close to Denton town centre. It is also close to the M60 and M57 motorways. There is ample parking for those who choose to travel to the home by car. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 5 Information about the service is provided in the form of a service user guide, a copy of which is available in each resident’s bedroom. A brochure is also displayed in the reception area and is available on request from the manager. The most recent inspection report is also available on request from the manager. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection started at 9.15pm on Wednesday 17th May 2006 and continued the following day. Time was spent talking to residents, relatives and staff and observing the home’s routine and staff interaction with residents. Four residents were looked at in detail, looking at their experience of the home from their admission to the present day. A tour of the building was conducted and a selection of staff and residents’ records was examined including records of care, medication records, employment and training records and staff duty rotas. Since the last inspection concerns have been raised through adult protection procedures about the care of one of the residents who was admitted to hospital, which highlighted shortfalls in the home’s record keeping. The home has agreed to take action to rectify these shortfalls. Prior to the inspection, comments cards were sent to GP’s and other professionals who visit the home on a regular basis. At the time of writing this report 2 responses had been received which provided mainly positive views of the home. One comment card was also received from a resident, who stated that they only sometimes liked the food and did not feel that suitable activities were provided. However they also stated that they felt well cared for, safe and that their privacy was respected. What the service does well: Visitors are made welcome at the home and the staff are friendly and pleasant. The atmosphere in the home is relaxed and informal and residents said there were no strict routines and they were able to choose for themselves how to spend their day. Good quality, home cooked food is provided and special diets are well catered for. Residents’ bedrooms are cosy and personalised with ornaments and mementos. Some residents have brought items of furniture into the home. All the residents spoken to liked living at the home. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? What they could do better: Although the home has a Statement or Purpose and Service User Guide to provide current and prospective residents with information about the services provided, some of the detail contained in these documents was inaccurate and needs to be updated. Residents must also be given detailed terms and conditions stating how much they must pay and what services are included in the fees. Although as stated previously some improvements have been noted in the quality of care plans, more rigour is still required to ensure that information obtained as part of the assessment is documented clearly and used to develop a relevant care plan to inform staff the actions they must take to properly care for the residents. Records were often not accurate or were incomplete although staff were very knowledgeable about residents’ needs – some of their knowledge seemed to have been gained by word of mouth rather than in a formal and consistent way. Procedures for the management of medicines were in the main satisfactory but a small number of shortfalls need addressing. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 8 Staff training should now become a priority as the manager acknowledged that this is an area that needs to be improved to ensure that all staff have the skills and knowledge to care for the residents effectively. An environmental health inspection took place at the home two days before this inspection and identified several areas that required attention. The registered person needs to make sure any requirements are met and also needs to ensure that deficits found in the annual service of the building’s fire detection equipment and emergency lighting systems are rectified. 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 Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 9 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 Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome area is poor. Residents do not receive sufficient written information regarding the terms and conditions of their stay; therefore residents may not always be clear about the services the home provides to meet their needs. The quality of assessment records across the home is inconsistent; therefore information may not be readily accessible to staff on some units and residents’ needs may not be clearly identified. Further staff training is required in topics specific to the needs of the residents staff are caring for. This judgement has been made using available evidence including a visit to this service. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 11 EVIDENCE: Service user guides are displayed in all residents’ bedrooms but were at the time of the inspection in the process of being reviewed and amended as some of the information provided was no longer accurate. Residents do not receive a contract or statement of terms and conditions on entering the home. Residents funded by the Local Authority receive a copy of the individual service agreement between the Local Authority and the home but this does not provide any information about how much of the fee they have to pay or what is included in the fee and what additional services or goods they have to pay extra for. The assessment details for three residents who had been admitted quite recently to the home were examined. The quality of the information obtained about these residents during the assessment process was variable with two care files containing detailed assessments and one assessment being very limited. The assessment for the first resident had been written by staff at the home on the day of the resident’s admission and there was no care management plan from social services on file, so it was unclear as to whether any proper assessment of the resident had taken place before the decision had been taken to admit him to the home. The details obtained on the day of the resident’s admission were fairly comprehensive although some risk assessments had not been completed such as the resident’s moving and handling assessment, falls risk assessment and pressure sore risk assessment. In the second resident’s care file an assessment from social services had been provided and all the information contained in that had been transferred to the home’s own admission records together with further information gained by staff during their own assessment of the resident. There were some details for both of these residents about their social history, previous occupations and family contacts. The third resident also had a care management plan from social services contained at the back of their care file but a lot of the information provided in that had not been transferred to the home’s own admission records and was not therefore easily accessible to staff caring for him. An assessment of the resident’s daily living activities was extremely limited and the information that had been obtained had not been used to develop proper care plans for how the staff were to meet the resident’s needs. No risk assessments had been undertaken. Despite this it appeared that the resident’s needs had been communicated verbally to all staff at the home as all staff were aware of his needs including the chef as the resident required a special diet. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 12 Although staff stated that they had received some training in mandatory health and safety topics such as moving and handling it was commonly acknowledged that further training was required in a range of subjects such as dealing with challenging behaviour and the protection of vulnerable adults. This issue is discussed more fully elsewhere in this report. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 13 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 and 10 Quality in this outcome area is adequate. The quality of care plans and risk assessments across the home is inconsistent; therefore information may not be readily accessible to staff and residents’ needs may not be clearly identified or addressed. Some procedures in respect of the receipt and administration of medicines put residents at risk. Residents feel they are treated with respect and their privacy is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for four residents were examined. Again as with the assessment records, the quality of care planning for residents was variable. The care plans for two residents were detailed, person-centred and had been reviewed monthly or more often if required. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 14 Risk assessments had not been completed on admission for the other two residents and where risk assessments had been undertaken that identified risk, there was not always a corresponding care plan to manage and reduce the risk. One of these residents who had been at the home for five days did not have any satisfactory care plan at all. Care plans had not always been developed to address all the needs identified during the assessment process; care plans had also not always been implemented to address needs that were identified after the resident’s admission although there was evidence from the daily records that staff had taken appropriate action such as contacting the GP. Proposed interventions stated in care plans were not always carried out in practice, for example the care plan for one resident stated that they should be weighed weekly but they had only been weighed every fortnight; furthermore the record of weights was confusing as staff had used two different forms within the resident’s care file to record the weights on. Wound care records were not kept with the residents’ care files but on a separate chart in the nurses’ office. Wounds had not been mapped or photographed and the daily report contained insufficient detail about the progress of treatment. The falls prevention team had been contacted for one resident who had suffered several falls. Three of the four care files contained no social care plans for residents to address how their need for social stimulation would be met. Two of the four files had been signed by the residents’ representatives to indicate the contents had been discussed and agreed with them. One resident and their relative who was visiting said they had not seen their care plan but they were not interested in doing so. One resident said the nurse had been and discussed the care plan with her and she had signed it. Medication administration records were examined. Medicines had not been signed for on receipt into the home in a number of cases. Staff members with responsibility for medication administration were identified by the means of a staff signature sheet, which was located in the medication administration record file. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 15 The home utilises resident photographs as a formal system of identification prior to medication administration. On the day of inspection there were a number of resident photographs missing. Some medication administration details were handwritten. These transcribed details had not been signed, dated or validated by an additional member of staff. The treatment room on the first floor was very warm. Staff should record and monitor the temperature of the room to ensure that it is maintained at a suitable temperature for the storage of medicines, as the majority should not be stored in temperatures above 25˚c. Since the last inspection a new refrigerator has been purchased for the storage of medicines and a daily record is maintained of refrigerator temperatures. Controlled medicines had been stored and recorded satisfactorily. During the inspection residents generally appeared well presented, clean and tidy. Staff were observed to treat residents with respect and patience. Residents said that staff were kind and friendly. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 16 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 and 15 Quality in this outcome area is adequate. Efforts have been made to expand and develop the range of activities provided for residents but further consultation is needed to ensure that the home satisfies all of the residents’ social and recreational needs. Residents are able to exercise some choice in their daily living routines and visitors are encouraged and welcomed into the home. Dietary needs of residents are well catered for and there is a balanced and varied selection of food that meets residents’ tastes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This inspection started at 9.15pm on the evening of 17th May 2006 and continued the next morning. At the time a small number of residents were still up in the lounge watching a football match on television with some visitors. A number of other residents were still up watching television in their own rooms. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 17 Residents said routines were fairly flexible in the home and they were able to choose what time to get up and go to bed and how and where to spend their day. One resident said she went to bed late, as she liked to watch television. One resident said life at the home was “monotonous” and there was “nothing to pass the day” but felt he had been too ill to socialise much or want to be involved in activities. Another resident said he spent a lot of time watching television and sometimes went in the garden if it was nice weather and went to the park on Sundays with his relatives, as he liked to listen to the bands. However this resident said there were not enough activities going on in the home. Since the last inspection staff have started to record activities that have taken place within the home and which residents participated in them and enjoyed them. Examples of some activities that had been provided included ball games, board games, bingo, hand massage and keep fit classes, which are held every Thursday. Social care plans were not available for all residents and the home is in the process of developing a key worker system. There was little evidence that staff had considered how to address the more diverse needs of residents, for example there had been no recognition of the particular needs of one resident who had to leave the home to attend hospital three times per week and how that may affect his social life within the home and his ability to form friendships and relationships with other residents and staff. More thorough care planning for the residents’ social needs and the proper introduction of a key worker system could help in creating person centred social activities tailored to individuals’ preferences. One relative said staff treated visitors well and another visitor said she had recently started to come and have Sunday dinner with her relative and felt she was made welcome. One resident was very happy with his room and had been able to bring a settee from home and other favourite ornaments and objects. Rooms were generally personalised and homely. Lunch on the second day of the inspection was shepherd’s pie and green beans, which looked and smelled very appetising. Some residents had an alternative of fish and chips. The dessert was pineapple upside down pudding or ginger sponge and custard for residents requiring diabetic diets. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 18 On each floor residents were served their meal by either the chef or the kitchen assistant, both of who were aware of which of the residents required special diets, which was served to them accordingly. Tables were nicely set with tablecloths and jugs of juice. Staff assisted residents discreetly if necessary and the overall atmosphere in both dining areas within the home was pleasant and relaxed. Residents said the food provided by the home was very good; one resident said it was “beautiful”. Another resident said they could have a cooked breakfast every day if they wished and they liked eggs. This resident did not think there was much choice of meal at lunchtime but said the food was always nice; tea she said was usually soup and a choice of a hot light meal such as beans on toast or sandwiches and cake. All residents said they were offered hot drinks and snacks between meals and at the start of the inspection at 9.15pm the leftovers of homemade cake were in the kitchen that residents had been served for supper. Discussion with the chef confirmed that she was aware of the dietary requirements of all the residents and took great pains to ensure that the food they received was appetising and appealing, for example one resident needed a salt free diet and the chef used different herbs and spices to ensure his meal was still tasty and flavoursome. Whilst a second option is not displayed on the menu the kitchen staff are very aware of residents’ preferences and provide alternatives to the main meal in discussion with the residents. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. The home has a satisfactory complaints system with some evidence that residents’ views are listened to and acted upon. Staff require training to ensure that all residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is provided in the service user guide. It states timescales by which a complainant can expect a response and gives contact details for the CSCI. A record of complaints received indicated that there had been 3 since the last inspection. The record included details of any investigation and response by the home. At the time of writing this report one complainant was waiting for a response directly from the registered provider as the manager had responded to one part of the complaint but had been unable to answer another part as it was directly addressed to the provider. In early May 2006 concerns had also been raised regarding the welfare of one resident who had been admitted to hospital. Minutes of a meeting that took Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 20 place on 5/5/06 between the home and social services provided details of some actions that the home had agreed in order to address the issues that had been highlighted. A notice was displayed in the satellite kitchen on the ground floor referring staff to the home’s policy for the protection of vulnerable adults. The notice informed staff where to find the policy and further advised that any concerns could be reported either to the manager or the registered provider. It went on to state that if the staff member was not happy to report any matter within the home they could contact the CSCI and contact details were provided. None of the staff spoken to had received training in the prevention of abuse or dealing with challenging behaviour. One member of staff said they had read the policy and several said they would report any suspected abuse to the manager but were not aware of external agencies that could be accessed. The manager had recently obtained training DVD’s covering a range of subjects including prevention of abuse and dealing with challenging behaviour and was intending to commence a training programme using this material imminently. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 21 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, 21, 24 and 26 Quality in this outcome area is adequate. Improvements have continued in the communal areas and residents’ rooms, but further progress is still needed and the home needs to comply with requirements from the environmental health department. Bathing facilities do not meet all the residents’ requirements. The home presented as being fairly clean but the effect was spoiled by a strong malodour on the ground floor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection work has continued to improve the environment. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 22 Many of the bedrooms have been redecorated and new carpets have been purchased for a proportion of them whilst it is planned to steam clean others. On the second day of the inspection four carpets were being fitted. New lighting has been provided for most areas of the building with the exception of a small number of rooms where the residents chose to keep the light fittings they already had. The result has been that the home appears much brighter. The hallways on the first floor have been redecorated and appear much cleaner and fresher. Several rooms have benefited from new sets of bedroom furniture and new garden furniture has been obtained and work is in process to improve the appearance of the external grounds. The manager has a clear programme for continued redecoration and refurbishment and is making good progress in achieving it. At the last inspection a bathroom on the ground floor was being converted to a disabled shower room. However this work has still not been completed and consideration must also be given to another bathroom on the ground floor, as the medibath installed there is not suitable for use. The home’s statement of purpose erroneously reports that the home has specialist baths for the use of residents when in fact neither are operational; therefore this work needs to be completed and the statement of purpose amended accordingly. The satellite kitchen on the first floor requires decorating as the wallpaper is peeling and paint is flaking from the ceiling. The armchairs in the ground floor lounge need replacing as many are stained and showing signs of wear and tear. A strong malodour was detected in the ground floor lounge although the majority of the rest of the home was fairly clean and tidy. Residents and visitors said cleaning staff came to clean the rooms on a daily basis. An environmental health inspection took place at the home on 16/5/06. A number of contraventions were identified and requirements were made for them to be addressed. The manager said that these would be dealt with. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 23 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 and 30 Quality in this outcome area is adequate. Some progress has been made in addressing staffing shortages and as a result residents are receiving more consistent care. The percentage of care staff working at the home who have completed NVQ training nearly meets the required targets. Insufficient records were kept at the home to evidence that full checks had been completed prior to an employee commencing work at the home so it was unclear if residents were protected. Limited training in specific topics has taken place so it cannot be certain that all staff have the skills and knowledge to care for the residents properly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of staff duty rotas indicated that staffing ratios generally complied with previous levels agreed with the former registering authority. Some residents and staff thought that the home was understaffed on occasions due to sickness for example but some improvement was apparent from the last inspection. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 24 The manager is still waiting to commence the Registered Managers Award and is still waiting for the start date for approximately eight care staff who wish to undertake NVQ training through Tameside Consortium. Of 19 care staff, nine have achieved at least a NVQ level 2 or equivalent, which falls just short of the 50 required target. Examination of staff files indicated that staff had been recruited following completion of an application form with detailed employment history, provision of two references including one from the most recent employer and an interview with the prospective employee. Disclosure certificates had been obtained following the employees commencement of employment but there was no record in the home that a POVA first check had been undertaken as the manager thought the record may be kept at another home within the group. Details such as these should be kept on the individual personnel file. As previously stated the manager was due to commence a training programme for staff, via DVD packages and accompanying questions to test the learners understanding. The training records were not available for inspection as the area manager had taken them off site but the manager acknowledged that staff training was an area that needs developing. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 25 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 and 38 Quality in this outcome area is adequate. The manager has a good understanding of the areas in which the home needs to improve and is capable of moving the home forward. There are limited systems in place to enable residents to offer opinions about how the home is being run; these need to be expanded. Financial procedures are in place to assist residents with their finances. More rigour is needed in completing and recording health and safety checks of the building and equipment but staff practices were generally satisfactory. This judgement has been made using available evidence including a visit to this service. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 26 EVIDENCE: The manager is registered with the CSCI. Staff said that the manager was supportive and approachable and that a number of changes had been made for the better. Several people said that they would like to see the manager out and about around the home more – one visitor said the manager always seemed to be busy in the office. Similarly both staff and residents said they did not really get any opportunity to speak with the registered provider who tended to confine himself to speaking with the manager. In order to properly form an opinion about how the home is running the registered person should seek the views of staff, residents and visitors. Two of the care staff said there had been a meeting about a week previously but neither of them had been able to attend; they were however waiting for the minutes of the meeting to be distributed. A meeting for the nurses had been held a few days later. There had been no meetings for residents or their representatives but questionnaires had been sent to all residents or their families in March 2006 and six responses had been received; comments had been mainly positive, saying that staff were helpful and friendly but residents could possibly benefit from more activities. The financial records for residents were not readily available as the administrator was on holiday. The manager stated that a separate bank account was held for the safekeeping of any money belonging to residents and that separate ledger sheets were kept for each resident detailing a running balance of how much each resident has in the account. The manager was not sure regarding the arrangements for the payment of any interest on the account; therefore residents’ finances will be considered again at the next inspection. The maintenance person undertakes some health and safety checks of the buildings and equipment but there was no evidence that identified shortfalls were always rectified, for example it had been recorded on 9/3/06 that emergency lighting was needed in the laundry, cellar, meter room and one of the resident’s bedrooms and three detectors were required but there was no record as to whether these shortfalls had been addressed. Staff were observed to be using safe working practices and had generally received mandatory updates in health and safety related topics. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 27 Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 28 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 2 2 2 2 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 29 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 OP1 Regulation 4 Requirement Timescale for action 31/07/06 2 OP2 5 3 OP3 14 4 OP7 15 The registered person must ensure that the home’s Statement of Purpose and Service User Guide are up to date and accurate in the information they provide. The registered person must 31/07/06 ensure that all residents receive a copy of the terms and conditions of their stay at the home, including all the details stated in NMS 2.2 The registered person must 07/07/06 ensure that detailed assessments are undertaken for all residents prior to them entering the home and that information gained about residents during the assessment process is accessible for all staff caring for them.. The registered person must 07/07/06 ensure that residents care plans set out in detail the action that needs to be taken by staff to ensure all aspects of the health, personal and social care needs of the residents are met and must ensure that actions detailed in DS0000043576.V292873.R01.S.doc Version 5.1 Thorncliffe Grange Nursing Home Page 30 5 OP7 13 6 OP8 17 7 OP9 13 8 OP9 13 9 OP9 13 10 OP12 16 11 OP18 13 12 OP19 23 the care plans are carried out. The registered person must ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated by the development and implementation of associated care plans. (Timescale of 15/1/06 not met). The registered person must ensure that the incidence of pressure sores, their treatment and outcome are recorded in the resident’s care plan. The registered person must ensure that handwritten medication details on the medicines administration records are signed and dated, and the details are validated by an additional member of staff. (Timescale of 15/1/06 not met) The registered person must ensure that medicines are checked and signed for on receipt into the home. The registered person must ensure that photographs of residents used for identification purposes are kept up to date. The registered person must ensure that residents are consulted about their interests, and make arrangements to enable them to engage in local, social and community activities and provide facilities for recreation. (Timescale of 30/1/06 not met). The registered person must ensure that staff receive training in prevention of abuse and dealing with challenging behaviour. The registered person must ensure that the requirements made by the environmental DS0000043576.V292873.R01.S.doc 07/07/06 07/07/06 07/07/06 07/07/06 07/07/06 31/07/06 31/08/06 16/07/06 Thorncliffe Grange Nursing Home Version 5.1 Page 31 13 14 OP19 OP20 23 16 15 OP21 23 16 17 OP26 OP28 13 18 18 OP29 19 19 OP30 18 20 OP33 24 21 OP38 23 health department are complied in the timescales specified. The registered person must ensure that the satellite kitchen on the first floor is repainted. The registered person must ensure that armchairs in the ground floor lounge are recovered or replaced. The registered person must ensure that the ratio of usable assisted baths provided to residents remains the same as was provided at 31st March 2002 (Timescale of 15/1/06 not met). The registered person must ensure that the home is kept free from offensive odours. The registered person must ensure that care staff are supported to undertake NVQ training to ensure that the target ratio is achieved. The registered person must ensure that evidence is available of all checks completed on staff prior to their employment at the home. The registered person must ensure that a training programme is implemented for staff that provides training specific to the needs of the residents they are caring for to ensure that they have the skills and knowledge to meet the residents needs. The registered person must ensure that an effective quality assurance and quality monitoring system is established which provides for consultation with residents and their representatives. The registered person must ensure that emergency lighting and smoke detectors are provided as identified at the last DS0000043576.V292873.R01.S.doc 31/07/06 30/09/06 30/09/06 07/07/06 30/09/06 07/07/06 31/08/06 31/08/06 07/07/06 Thorncliffe Grange Nursing Home Version 5.1 Page 32 service by the contractor. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP8 OP9 Good Practice Recommendations The registered person should ensure that wounds are photographed with the resident’s consent to aid evaluation of treatment. The registered person should ensure that the temperature of the treatment room is monitored and recorded to ensure that it does not exceed 25ºC. Thorncliffe Grange Nursing Home DS0000043576.V292873.R01.S.doc Version 5.1 Page 33 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. 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