Inspection on 11/07/07 for Thorncliffe House

This inspection was carried out on 11th July 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 House 12/06/06

Thorncliffe House 17/01/06

Thorncliffe House 06/09/05

Thorncliffe House 25/11/04

Thorncliffe House 23/06/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Thorncliffe House 15 Thornhill Park Sunderland SR2 7LA Lead Inspector Mrs Eileen Hulse Key Unannounced Inspection 08:45 11 and 24th July 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 House DS0000059954.V340501.R02.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 House DS0000059954.V340501.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thorncliffe House Address 15 Thornhill Park Sunderland SR2 7LA 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) 0191 510 9736 F/P Mr Philip Longmore Mrs Margaret Elizabeth Kirkwood Care Home 19 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (19), of places Physical disability over 65 years of age (2) Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th June 2006 Brief Description of the Service: Thorncliffe House is a registered care home, which provides permanent accommodation with personal care and support for up to a total of nineteen older people, some of whom may have dementia needs. Within this total, the home may also provide a service to a limited number of adults with a physical disability. Nursing care cannot be provided. The property is a three storey Victorian detached house, with bedroom accommodation and WCs on each floor; bathing areas are located on floors one and two. A passenger lift serves all three. Located on the ground floor, are a large lounge and a further open-plan lounge/dining room for communal use. Situated in a quiet cul-de-sac close to the centre of Sunderland, the home is near shops, parks and transport networks. There is a large, well-kept garden to the front, which Service Users may enjoy in fine weather and at the side, a wide secure area with a ramp, which enables access for people with impaired mobility. The rear ‘yard’ is soon to be converted into a pleasant patio. The home is currently completing building work to the rear of the building to extend the property to provide another five residential places, while at the same time improving the access and standards of the existing building and its grounds for service users. The home has developed a Statement of Purpose and Service User Guide that inform prospective and current service users about the service, the aims and how these are met. These and a copy of the recent inspection report are available in the home for anyone to read. The weekly fees are £372.00 to £387.00 per week depending upon care needs. Additional charges are made for hairdressing, personal items and newspapers and magazines. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took 9hrs 45mins to complete over two days visiting the home. It followed a random inspection that was carried out on the 12 January 2007 to see if any progress and improvements had been made to the service. The Registered Manager was present throughout the visits and some time was spent with her looking at systems they have in the home such as staffing levels, staff training, medication systems and spending time in communal areas of the home. Time was also spent talking with service users and their visitors to get their views about the home. How care staff help and support service users was observed throughout the visit and a lunchtime meal was taken with the service users. Information about the quality of life and care received by service users was collected using a system called ‘case tracking’. This involves following the care and experience of a group of service users by looking at care plans, talking with people, sampling records such as assessment records, complaint records, medication taken by service users and their records. Issues that we asked the home to put right in previous inspection reports were discussed with the Manager and the provider who was in the home for part of the day. Discussions also took place with other staff members who were on duty at various times throughout the visit. The judgements made are based on the evidence made available during the visit to the home and from details obtained from the home before the visit was made. This gave up to date information about the home to include within the report. During the visit comments from service users and their families gave some insight on what it is like to live in the home and included: ‘It’s a nice place this’ ‘The staff are first class in here’ ‘I enjoy the company and the girls (staff) they are really nice’ ‘The staff are really helpful and the owner always has a word for everybody’ ‘I am pleased I chose this home, more than happy with it’ What the service does well: The home makes sure that all prospective service users have the information they need before deciding to move into the home. Their needs are assessed so that the home knows they can meet the needs before the service user moves in. Good healthcare arrangements are made available with district nurses, chiropodists etc visiting the home regularly. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 6 The quality of food is good and service users likes and dislikes are taken into account and they can choose from a number of options on the menu what they would like to eat. The staff team are caring and committed and respectfully offer all service users the help they need in the dining room in a dignified manner. All staff receive good training and this helps people to know they will be well looked after regardless of their various needs. The home is clean and generally well looked after and provides a comfortable and homely place for service users to live in. 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 House DS0000059954.V340501.R02.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 House DS0000059954.V340501.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home uses a good assessment and admission process that ensures the needs of people can be met prior to their admission. The home does not provide intermediate care. EVIDENCE: The homes admission and assessment procedure ensures that service users can make an informed decision about coming into the home. They are given information before visiting the home that informs them how their care needs are to be met. A care Manager is involved with the process and provides the home with a care plan prior to admission. Several visits are then arranged between the service user and the home before admission, to give people the choice if they would like to live there. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Service users have regular access to healthcare professionals and this promotes their welfare. However, the care plans do not include enough information that will ensure staff are meeting the needs of service users and the medication system used does not ensure that service users are kept safe. EVIDENCE: All service users have a plan of care that is followed by staff to meet the care needs. The care plans do not contain sufficient information that staff can follow. Each care plan has an identified need and a goal to meet the need but there is no information that will tell staff how to do this. The care plans are not monitored or evaluated to show staff if there are any changes needed to the records. The care plans are organised and in some areas detailed but they are bulky, with some out of date information that needs to be transferred to a holding file. The home continues to use a daily report book and the information is then transferred into a daily file. This file Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 10 contains shave, fluid, bath, continence and bed changes sheets for every service user living in the home. This kind of record is not necessary and does not conform to the Data Protection guidelines or respect the dignity of service users. Risk assessments are located within the care plans but they contain only limited information and do not inform staff how the risk can be managed. The home uses a monitored dosage medication system and these are delivered to the home from the pharmacy on a monthly basis. At the same time any unused or unwanted drugs are collected and returned to the pharmacy. MAR (medication administration document) sheets and the returned drugs book were signed and up to date. However, some PRN medicines currently being used were found to be out of date, the medicines were dated as 3/4/07 and 9/3/07 and this can cause confusion. All unused medication should be returned to the chemist every month. Other medicines not in a monitored blister pack and in their original box were in use without a name on them and the information supplied by the chemist located on the box had been destroyed. No controlled drugs are in use at this time and there is a medical fridge in use for medicines that need to be stored under a certain temperature. The Manager and staff team are currently completing the ‘Safer Handling of Medication’’ Comments from service users and families included: ‘I am 90 blind the staff give me all the help I need, they are so caring’ ‘My (relative) has been here a while now and seems quite happy’ ‘Very very good individualised care for my (relative)’ ‘The girls are really nice and look after my (relative) really well’. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of spontaneous activities both in the home and the local community but they are not planned or recorded and therefore do not give service users the opportunity to plan how they would like to spend their days. The quality of food is good and service users are able to choose options from the menu, making sure that likes and dislikes are taken into account when planning the menus and that dietary needs are met. EVIDENCE: The home employs an activities co-ordinator twelve hours a week to organise outings and activities within the home but they are not planned in advance or recorded to get the views or comments from service users taking part in the events. Some service users can go out independently to the local shops, the bank and the local library. Outings in small numbers are open to all service users regardless of their abilities and past outings have included visits to the Winter Gardens and the Stadium of Light Tour. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 12 In discussions with some of the service users, there were mixed comments on how they fulfil their days and they included: ‘We are getting a greenhouse and I am looking forward to it, I used to have allotments’ ‘Sometimes there are things going on’ ‘I get sick of just sitting here doing nothing’ ‘I prefer to spend my time in my room watching TV’ ‘We don’t have any trips out here’ During the visit, a meal was taken with the service users. Tables were well set and the meal was hot, tasty and wholesome. Throughout the meal, service users stated: ‘We get good meals in here and you can always choose what you want to eat’ another service user said ‘You can have anything you want in here, my best meal is my breakfast’. One service user likes tripe and this is purchased once a week. Many service users choose to have breakfast in bed, as was observed during the visit, while others can choose to have breakfast when they prefer it between 8.30-11am. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All staff have received safeguarding of adults training and procedures are made easily available to them, however, any concerns or complaints made to the service are not dealt with effectively. This does not give people the confidence that their concerns will be dealt with satisfactorily. EVIDENCE: The home have detailed procedures regarding complaints and concerns to follow should anyone wish to raise a concern or complaint and information is given to service users following their admission. Service users know how to make a complaint and comments were: ‘I would see the owner if I had a problem’ ‘The girls would help me if I needed to complain’ ‘There is nothing to complain about in this home’ In discussion with the Manager it was highlighted that any concerns or complaints made are not recorded. The Manager stated that they are dealt with at the time. This does not give the complainant the confidence that their complaint has been dealt with properly. The staff are aware of the action they should take should an abuse situation be suspected. Staff stated: Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 14 ‘We have received protecting adults training, it was really good’ ‘I feel more confident having had the training, I would know what to do now’ Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is clean and generally well maintained and a number of improvements have been made in recent weeks, this ensures service users live in a comfortable and homely environment. All staff have received infection control training and this helps to protect the well being of service users. EVIDENCE: Although the building work to the extension at the back of the home is still going on, some improvements internally have been carried out. The planned refurbishment of the bedrooms is now complete and many of the bedrooms have been decorated and refurbished with new furniture, carpets, curtains and bedding and all the corridors throughout the building have had the carpets replaced. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 16 The service has worked hard to address many of the requirements made in the last report. The number of bathing facilities has improved and the home now have one assisted bath and a walk in shower and there is to be ramped access to the rear of the home to enable all service users living in the home to have access into the garden. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 17 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. Well-trained, caring and committed staff are in post with good staffing levels. This ensures that staff have the knowledge and skills to care and support people. Service users are protected by the home’s robust recruitment procedures. EVIDENCE: The home have a staff training matrix of completed training showing that all care staff have completed NVQ level 2 and acquired a care qualification and also shows other courses they have completed. This matrix was up to date and although the name, the provider of the training and the qualification obtained is recorded, it does not show when the training was completed or when the next mandatory training is due. The home has a policy and procedure that is followed when recruiting prospective staff. The Manager was able to explain in detail how the procedure is carried out. There are currently three male carers working in the home to give service users the choice of who assists them in their daily living tasks. A sample of staff files showed that all the checks, which must be carried out prior to employment, were in place. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 18 Prior to confirmation of a post, the prospective member of staff is invited into the home to spend some time with a member of staff. Adequate numbers of staff were on duty and the rotas confirmed the staffing numbers are consistent. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 19 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a person who has experience and is able to manage the service competently and the risks to the health and safety of service users, visitors and staff are minimised. However, the medication system in use does not protect the service users at all times. EVIDENCE: The Manager has worked in various care settings for almost twenty years. She was registered as Manager of the home in January 2007 and has almost completed her Registered Managers Award and has achieved NVQ levels 2/3. She has recently updated her knowledge and skills by completing a number of training courses including fire safety, food handling and is currently completing the ‘Safer Handling of Medication’ training. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 20 Staff were observed to follow health and safety guidelines throughout the two visits to the home and both the accident documentation and fire logbooks were up to date and well maintained. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 21 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 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 3 X 3 X 3 X X 2 Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 The care plans must contain sufficient information to inform staff. They must be monitored and evaluated and contain detailed risk assessments 2 OP9 13 All unused or out of date medication must be returned to the pharmacy and medication system must be reviewed 3 OP9 13 Any member of staff administering medication must attend accredited training in the administration of medication. Timescale of 28/02/07 not met 4 OP12 15 All activities must be recorded within the plan of care 5 OP16 17 All complaints must be recorded detailing details of the investigation and actions taken Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 23 Requirement Timescale for action 01/10/07 01/10/07 01/10/07 01/10/07 01/10/07 6 OP31 9 The manager must successfully complete the Registered Managers Award and begin NVQ4 in Care. Timescale of 30/12/06 not met 01/10/07 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 OP27 Good Practice Recommendations The staffing ratio should be reviewed in relation to the needs of the proposed additional service users prior to the proposed extension of the home being completed. Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. Extracts may not be used or reproduced without the express permission of CSCI Thorncliffe House DS0000059954.V340501.R02.S.doc Version 5.2 Page 25 - 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. 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