Inspection on 04/10/07 for Thorncliffe Grange Nursing Home

This inspection was carried out on 4th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Thorncliffe Grange Nursing Home 23/09/08

Thorncliffe Grange Nursing Home 17/05/06

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 John Oliver Unannounced Inspection 9:30 4 October 2007 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.V342140.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 Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 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 Sarah Hitchcock 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) Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 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). 17th May 2006 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 £331.75 to £456.75 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.V342140.R01.S.doc Version 5.2 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.V342140.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by us (the Commission for Social Care Inspection) in relation to the home prior to the site visit. The visit was unannounced and took place over the course of a total of 9 hours on Thursday 4th and Monday 8th October 2007. During the course of the site visit we spent time talking to residents, the manager, relatives and staff on duty to find out their views of the home. Before the site visit we sent the manager of the home an Annual Quality Assurance Assessment (AQAA) document for them to complete and return to us with information about the service they provide. This was returned to us before the visit took place and contained some information that helped us to assess the service being offered in the home. We also spent time examining resident and staff files, maintenance records and spent some time looking around the building. What the service does well: We found the atmosphere in the home to be relaxed and informal and residents spoken to say that they could choose for themselves how they would like to spend their day. Residents and relatives told us “You get well looked after here”, “They put me in the bath using the hoist”, “I love it here – the girls are nice” and “I am very happy with the service – (I am) always kept informed of mums health”. We saw a number of ‘thank you’ cards displayed on a notice board and comments in these cards included “ Many thanks for all the loving care that you have given…. over the last two years. You have looked after him so well, especially the nursing staff over the last few weeks. The care staff have been brilliant with him, jollying him along and feeding him etc. It gave me some peace of mind knowing that he was well fed and in a caring environment”. Residents told us about the food served in the home and said, “You get good food – you get choice”, “I like plain omelettes and I get these when I ask”, “I get decent food which is everything” and “The food is very good”. Staff told us that the manager was supportive and approachable and was working hard to improve things in the home. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with information about the home prior to admission but this needs to be improved. All prospective residents receive a full assessment of their needs before they move in. EVIDENCE: The Service User Guide and Statement of Purpose had recently been reviewed and updated by the manager. We (the Commission for Social Care Inspection) saw a copy on display in the hallway of the home and in each resident’s bedroom. Some of the information was not correct and an example of this was found on page 14, ‘Staffing Level - 1. Staffing levels must legally be maintained as directed by the Commission for social care inspection’. The levels of staff on duty, including nursing staff, are decided by the manager of the home in line with the day-to-day assessed needs of the residents. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 10 Also, on page 8 it is written, ‘Medication – 4. If you feel that you do need something like a cough linctus or headache pill, always ask the carer for help and they will identify suitable treatment’. Staff working in the home are not qualified to recommend or ‘prescribe’ suitable ‘homely remedies’ and this can only be done by a doctor. It is recommended that the Service User Guide be reviewed again to make sure all information is correct. The manager told us that since the last inspection visit in August 2006, all residents have received a copy of their terms and conditions with the home. At the time of this visit evidence was seen where a copy of terms and conditions for a new resident were being sent to their family (advocates) for signatures and one relative brought in a newly signed contract for her mum. Three residents’ files were examined. Different formats of pre-admission assessments carried out on behalf of the home had been used and this made information difficult to follow and assess. However, the file of a recently admitted resident was also examined and this contained a pre-admission ‘Daily Living and Needs Assessment’. This had been carried out by the manager prior to the resident coming to live in the home. Discussion with the manager confirmed that this would be the pre-admission assessment document used in the future to ensure consistency of information for staff. It was confirmed that intermediate care services are not offered in the home. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were in place that detailed the needs of the individual resident and supporting policies and procedures were in place to ensure the safe handling and administration of medication in the home. However, these policies and procedures were not always adhered to which could place residents at risk. EVIDENCE: Since we last visited the home in August 2006 the manager has developed and put into place newly designed care plans. These plans are detailed and gave directions to staff as to how to provide care to meet the resident’s assessed needs. Risk assessments were also included in those files seen and along with the care plans had been reviewed (and updated where necessary) on a monthly basis. We saw that one resident had signed a care plan agreement and family members or advocates had signed others. A separate file was kept with information relating to each resident being supported with wound care. There were 9 residents on wound care Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 12 programmes and photographs had been taken (with the permission of the individual) and diagrams drawn to highlight areas of wound. Nursing care plans were in place and included a wound assessment record. The record for one resident was examined and detailed information was in place and appropriate action had been taken. Evidence was available within notes and records to demonstrate that regular visits were made to residents by other health care professionals including GP’s, district nurses and speech therapists. Comments from residents and relatives spoken to included, “You get well looked after here”, “They put me in the bath with the hoist”, “I love it here – the girls are nice” and “I am very happy with the service – (I am) always kept informed of mum’s health”. A number of ‘thank you’ cards were displayed on the notice board in the hallway and comments in some of these cards include: “Many thanks for all the loving care that you have given…. over the last two years. You have looked after him so well, especially the nursing staff over the last few weeks. The care staff have been brilliant with him, jollying him along and feeding him etc. It gave me some peace of mind knowing that he was well fed and in a caring environment”. “We wish to thank you all for your devoted care of…. over the past 3 years. Your nursing skills, treatments and lots of personal attention definitely helped…. a better life. We know your tasks were more difficult over the past year when…. was completely unable to help herself. Also you were always good on the phone and great people to talk to”. A pharmacist inspector carried out an inspection of the service on 1 August 2006 to look at how well medicines were managed on behalf of residents. The judgement made following this visit was that medication practice was adequate. At the time we visited the home on Monday 8 October the manager was in the process of speaking on the telephone with the pharmacist of the supplying chemist. Due to the pharmacy having staffing difficulties not all the monthly medication was delivered on Saturday 6 October. Consequently, some residents were unable to be administered their prescribed medication on Monday morning as it had still not arrived. The manager had already written a letter of complaint to the manager of the pharmacy and provided us with a copy. Nursing staff have the responsibility of administering medication to those residents who require nursing care and senior care staff have the responsibility for administering medication to those residents who require residential care. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 13 Medication is administered via a monitored dosage system and those Medication Administration Records (MAR) checked were found to be correct and signed for accordingly. All medication received into the home had been recorded on the MAR. Where medication was still to be delivered the nurse in charge had made a record to demonstrate why medication would be given late and the reason. Photographs of residents were in place to help with ease of identification and where MAR sheets had been handwritten this had been verified with two signatures. A spot check of medication to be given ‘as and when’ required was carried out and balances were correct. Controlled drugs were stored appropriately and balance checks were found to be correct. No resident was self-administering medication at the time we visited the home and watching medication being administered by staff demonstrated that residents are clearly asked whether they need any medicines prescribed ‘when required’. A number of care plans were seen that described when painkillers might be needed for residents who are unable to communicate verbally. It would be good practice if care plans were also developed for the use of ‘when required’ medicines. This will help to make sure that residents receive the ‘when required’ medicines when needed. A number of residents had been prescribed a thickener to be added to all liquids to aid their swallowing. However, it was seen that the thickener for one resident had been put into an ordinary storage container and this was being used for all residents who required thickener. No record was being maintained of when thickener was being administered to the individual. All medication must be recorded when administered and must remain in the original container with the original administration instructions clearly visible. Medication must not be ‘shared’. Such practice can place the residents at risk from errors occurring in the administration of such medication. During the visit we saw that residents generally appeared well presented, clean and tidy and staff were seen to treat residents with respect, dignity and patience. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Daily routines in the home demonstrated that residents were encouraged to maintain control over their lives wherever possible although improvements are needed to ensure that appropriate social activities and stimulation are made available. Residents are provided with a wholesome and well balanced diet. EVIDENCE: At the time we visited the home the manager was in the process of reviewing the social activities available. Activities did take place but were on an occasional basis although arrangements had been made for one member of staff to be allocated 6 hours per week to further progress the activities that are available. Residents said that they would like to see more activities being made available to “pass the time of day”. Those files examined did contain a care plan addressing daily living and social activities. However, in most cases a lack of information about the person’s previous lifestyle regarding likes/dislikes, hobbies and activities they enjoyed doing had not been fully addressed and no record was kept of any activities Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 15 that individual residents may have participated in. Lack of such information makes it difficult to assess if peoples needs are being met in the most appropriate way. Visitors to the home were seen to come and go throughout the visit and examination of the visitor’s book demonstrated that lots of people visited the home on a regular basis. The kitchen is situated in the basement of the home and this area appeared to be very clean, tidy and well organised. A discussion with the cook on duty demonstrated that she understood people’s likes and dislikes and understood about individual residents dietary needs. Menus were planned using a three week rotating menu and these were displayed on the back of all bedroom doors to make sure residents had an opportunity to think about the meals they would prefer to order. On the day we visited the main meal was savoury mince and herb dumplings, mashed potatoes and green beans – alternative choices were made available. Staff were seen serving meals to those residents in the dining room on the ground floor. A number of residents needed varying degrees of assistance whilst having their meal ranging from needing food to be cut up to actually being fed their meal. The three staff did this sensitively and unhurriedly but this did mean that the more able residents had to wait a little longer for their sweet to be served. Residents spoken to about the meals in the home said, “You get good food – you get choice”, “I like plain omelettes and I get these when I ask”, “I get decent food which is everything” and “The food is very good”. One visiting relative said, “Mum enjoys the food – they accommodate her needs”. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and training measures were in place for staff to support residents to raise any concerns and to protect residents from neglect and abuse. EVIDENCE: The complaints procedure was displayed throughout the home including the hallway and in individual bedrooms. Residents and relatives spoken with during this visit were very clear about how to raise a concern or complaint. They did not keep an actual record of complaints only the letters of complaint sent into the home. They had received four complaints since we last visited and all appeared to have been satisfactorily addressed. In one instance, a letter of thanks had been sent to the manager for the way in which the complaint had been dealt with. It is recommended that an appropriate document be developed on which complaints received can be recorded. During this visit a relative came to the office to make a complaint about some issues surrounding meeting care needs. The manager dealt with this appropriately and respectfully and a letter was sent to the complainant confirming the concerns discussed and the action taken to resolve those concerns. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 17 We had received no complaints about the home since we last visited in August 2006. At the time we visited, the manager said that there was no protection of vulnerable adult issues and that staff had received training relating to this. Staff spoken with confirmed this and were clear about what action they would take in the event of an allegation of abuse being made. Comments from staff included, “I would go to the manager” and when asked what they would expect the manager to do said, “inform the contact centre”. Residents spoken to said, “I would speak with one of the girls” and “I would go to Sarah (manager)”. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was clean, tidy and comfortable however, some areas of the home could place residents at risk. EVIDENCE: Since we last visited the home in August 2006 a lot of work has been carried out to improve the living environment for the residents. Many bedrooms have been redecorated, refurnished and have had new carpets laid. At the time of this visit the maintenance person was in the process of redecorating a bedroom ready for a new admission. This room had already had new carpet laid. Those bedrooms seen were clean and bright and had been personalised to varying degrees to reflect the character of the individual whose room it is. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 19 Five new sets of bedroom furniture had recently been purchased and delivered to upgrade some more rooms. It was noticed during a tour of the bedrooms on the first floor that many windows did not have restrictors on them and they could be opened very wide. This presented a significant risk to some of the people whose rooms they are. A letter will be sent to the owner and manager to make sure that risk assessments and/or restrictors are fitted to those windows requiring them within the next seven days. A requirement has been made under National Minimum Standard 38. It is acknowledged that the manager requested the maintenance person to go and purchase sufficient restrictors for those windows needing them straight away. He was seen fitting these to the windows before the end of the first day of the inspection visit. The manager said that all radiators in bedrooms were low surface temperature in order to safeguard residents. New carpeting had recently been laid to the ground floor corridors, lounge and dining area and to the upstairs lounge and dining area. New armchairs had also been purchased and provided in the downstairs lounge. A number of doors (including upstairs lounge) were not closing into their rebates effectively. As these are fire doors this could place people at risk. An audit of all doors must be undertaken and adjustments made where necessary to ensure they close properly. Bathroom and toilets were appropriately maintained and those seen all had privacy locks in place. One bathroom had recently been upgraded with a new bath and chair hoist. The laundry area is sited in the basement area of the home and was found to be well organised, clean and tidy and equipped with appropriate washing machines and dryers. Hand washing facilities were also available for staff. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are employed in the home, with staff training and development helping to ensure staff are competent to carry out their jobs. Improved recruitment and selection processes helps to protect residents from unsuitable people working in the home. EVIDENCE: On the days we visited the home staffing levels appeared appropriate to meet the needs of those residents living in the home. However, discussion with a number of residents indicated that they thought there was a need for more staff on occasions and comments included, “Seems to be a shortage of staff at holidays” and “Staff are kept busy – could do with another one sometimes”. Again, in those survey questionnaires returned to us, both staff and relatives do mention that they have some concerns about the lack of staff at times and the risk that is sometimes placed on residents because of this e.g. “We have people that go walking and fall”, “Agency staff – I find not so good – you spend more time explaining what to do….you find yourself doing the shift on your own – they (agency staff) just fill the number” and “Staff should be available ‘ALWAYS’ – due to staffing levels this is not possible”. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 21 The manager carries out regular service audits and sends relatives, residents and other health care professionals questionnaires in order to assess what they think of the service. Of eleven questionnaires returned to the home by relatives, eight indicated that they felt there was some shortages of staff and comments included, “Short staffed now and again”, Most times staff is fine – about 1.30pm there does seem to be a short fall” and “Seems to apply at weekends”. Staff spoken to during this visit said, “Usually enough staff – but depends on who you work with – but generally a good team”. The manager had placed a number of advertisements in the local Job Centre to try and recruit some more staff. The area manager for the home visits on a monthly basis and produces a report from that visit. Copies of the reports from three visits were examined and there was no indication that any particular problems/issues had arisen from lack of staffing or had been reported to the area manager. Seven members of the care staff team had achieved a National Vocational Qualification (NVQ) level 2 and the manager confirmed that funding was in place for a further four staff to commence this training. One member of staff also held NVQ level 3 & 4. Examination of two staff files indicated appropriate pre-employment checks had been carried out prior to the person commencing employment in the home including a Criminal Record Bureau (CRB) enhanced check. Nurses PIN numbers are checked on a monthly basis. All staff received training and those staff spoken to during the course of this visit confirmed this. The manager has developed a document in which to record a full induction for all new staff in line with Skills for Care and was in the process of taking eleven existing staff through this as well. We saw a copy of a fully completed induction programme for a member of the care staff team who had commenced working in the home in January 2007. Arrangements were also being made for all care staff to be provided with Basic Food Hygiene training. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 39 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents living in the home benefit from having the support of a manager with skills to provide a good quality service. However, more rigour is needed when assessing health and safety checks around the home. EVIDENCE: The manager is very experienced and has numerous years of managing both nursing and residential homes. She has recently become registered as the manager of Thorncliffe Grange with the Commission for Social Care Inspection. Staff told us that the manager was supportive and approachable and was working hard to improve things in the home. Comments included, “Manager is out and about – talking with both staff and residents”, Sarah (the manager) is Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 23 very approachable – she listens to what you have to say” and “Good management – monitors and maintains care plans – she also does spot checks on medication to make sure it is being administered properly”. In order to maintain an overview of how well the service is meeting the needs of those people living in the home the management team carry out regular audits of the service using questionnaires, meetings and spot checks. The area manager also carries out monthly visits to the home and produces a report of that visit. A business plan has been developed for the service and this was readily available in the hallway of the home. The manager told us that a separate bank account was held for the safekeeping of any money belonging to residents and that separate ledger sheets are kept for each resident detailing a running balance of how much each resident has in the account. Staff told us that they regularly receive one to one supervision and records were kept of these sessions. Examination of staff files also demonstrated that staff work through various policies and procedures and sign to say that they have read and understood them. Examples were seen that included staff being taken through, Fire Procedures, Security, Visitors, Confidentiality, Record Keeping, Catheter Care, Medication, Accidents in the Home and Moving and Handling. It is also important that all staff who manage or take charge of the home in the absence of the registered manager are fully aware of policies and procedures used in the home and it is strongly recommended that all senior staff (including night staff) are taken through policies and procedures that may require them to take direct and immediate action e.g. Fire Awareness, Outbreak of Infection and Sudden Death. The manager confirmed within the Annual Quality Assurance Assessment (AQAA) returned to us before the inspection took place that the servicing and maintenance of all equipment used in the home had taken place. A random selection of reports relating to the maintenance of equipment were checked and included, fire alarm servicing, electrical installation (5 yearly), water check (Legionella) and gas safety, all were found to be in order. Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 3 3 3 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 3 X 3 X 3 3 X 2 Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13 (2) Requirement Medicines in the custody of the home must be handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971 and Nursing staff abide by the UKCC Standards for the administration of medicines. An audit must be undertaken of all fire doors and adjustments made where necessary to ensure that they close into their rebates effectively. An audit of all upstairs windows must be undertaken and appropriate action taken where window restrictors are not fitted. Timescale for action 12/11/07 2. OP19 13 (4) (c) 12/11/07 3. OP38 13 (4) (a) (c) 11/10/07 Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP1 Good Practice Recommendations It is recommended that the Service User Guide be reviewed and updated to include information that is current and correct. It is recommended that residents are consulted about their interests, and make arrangements to enable them to engage in local, social and community activities. It is recommended that a suitable format be developed on which to record complaints received by the home. It is recommended that the manager continues to monitor staffing levels to ensure that enough staff are on duty at any one time to meets the current needs of those residents living in the home. It is recommend that all staff with the responsibility for the management of the home in the absence of the registered manager are taken through policies and procedures that may require them to take direct and immediate action e.g. Fire Awareness, Outbreak of Infection and Sudden Death. 2. OP12 3. 4. OP16 OP27 5. OP38 Thorncliffe Grange Nursing Home DS0000043576.V342140.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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