Inspection on 12/06/06 for Thorncliffe House

This inspection was carried out on 12th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Thorncliffe House 11/07/07

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 Elsie Allnutt Key Unannounced Inspection 12th June 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Thorncliffe House DS0000059954.V298776.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 House DS0000059954.V298776.R01.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 5109736 0191 5109736 Mr Philip Longmore 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.V298776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 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 openplan 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. Plans are in place 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, however these plans have recently been put “on hold.” The home has developed a Statement of Purpose and Service User Guide that informs 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 range of fees charged by the home is between £359 and £374 per week. Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This scheduled unannounced inspection took 8 hours over one day in June 2006. The judgements made are based on; the evidence available to the inspector during the inspection, and the pre-inspection questionnaire supplied by the manager. Although comment cards were sent out to the home for service users and relatives to complete and to state their opinions about the home, none were returned prior to and since the inspection visit. However positive comments about the service delivered at this service from relatives and visitors were recorded in the home’s Comment Book and these were taken into consideration. Surveys were also sent out to the home for service users to complete but none were returned. A discussion with one relative was carried out during the inspection resulting in their satisfaction with the service being expressed. The views of ten service users and four members of staff were also sought during the inspection. As some of the service users have dementia or other problems and do not have effective verbal communication, their satisfaction of the service was understood through the observations of wellbeing, interaction with staff, discussions with staff and the examination of records. This process showed that the service delivered is satisfactory. A tour of the building took place, and samples of staff and residents’ records were examined. What the service does well: The friendly interaction of service users and staff create a warm and welcoming atmosphere in the home. Many of the staff have worked at the home for several years which means that they know their work routines and service users’ needs well. By observing life in the home and reading records it was evident that service users’ independence is promoted and they are supported to live a lifestyle that is based on personal preferences. Service users stated, “Philip (the Proprietor) and the staff always make our families and visitors welcome into the house.” “If you need anything the staff will get it for you.” “ We are well cared for.” Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 6 Relatives and friends commented, “My father couldn’t be better looked after.” “I’ve got no worries I know I will be informed if my mother is not well.” Prior to agreeing that the home can offer a service that meets prospective service users’ needs the home ensures that they receive detailed information from the person and Social Care and Health. This confirms that the service delivered in the home and the expertise of staff is appropriate for that person. Discussions with the service users confirmed the good range of food available, they said, “The food is always good, we get plenty” and “There is usually a choice of what to eat and it’s usually fresh food.” An ongoing training plan is underway to equip staff with appropriate skills and knowledge related to service users’ needs and guidelines in service users’ individual care plans guide staff how to meet their needs in a consistent way. . What has improved since the last inspection? The service that staff, lead by the manager, delivers at this home, continues to improve. The manager and staff continue to work hard to establish the new, effective care planning system. Each service user has an individual care plan and those plans that have been transferred to the new system are clearly set out and include appropriate information covering different aspects of care. The risk assessments and guidelines explaining how a risk can be reduced are now an integral part of the care plan and are clear for staff to follow. This reduces identified risks and supports service users to remain safe yet take part in daily activities they enjoy. Training opportunities for staff have also developed and all staff are now qualified in NVQ 2 or above and have attended training regarding the local authority’s adult protection procedures and the administration of medication. This gives staff the skills and knowledge needed to address the needs of the people living at this home. So that her skills and knowledge also continue to develop the manager has started a training course that will equip her with the appropriate skills and knowledge required by a manager to run the home safely and effectively. This will ensure that the service received by service users is safe and appropriate. Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 7 Another four bedrooms have been attractively redecorated and refurbished as part of the homes improvement plan. This has provided more service users with attractive and comfortable accommodation. What they could do better: Although many of the requirements of previous reports have been met some, although they are being addressed, have not yet been fully met. Medication recently prescribed by the GP for a service user had been given to the service user, but not signed for. This meant that it was not certain whether the service user had received that particular medication or not and could have resulted in more medication being given causing a risk of harm to the service user. The medication received by the home, although checked against the order submitted by the home to the pharmacist, had not been recorded on the medication record sheet. There was no record confirming therefore that the quantity of the medication received by the home matched the quantity recorded by the pharmacist. This could cause confusion at a later date and service users could be left short of medication with no record to prove that the quantity of medication received was incorrect. The home should always follow the guidelines set by the Pharmaceutical Society in The Administration and Control of Medicines in Care Homes. So that the rights of service users are addressed, in the event of a decision being made that restricts a service user from having a key to their bedroom, the reason should be recorded in the individual care plan and should be the outcome of a risk assessment. Due to the fact that the proposed plans to extend the building have been “put on hold” consideration must be given to the improvements needed throughout the building that were to be addressed during and after the building work. This is so that service users will benefit from the improvements as soon as possible. For example the remaining service users bedrooms will be refurbished, the furnishings showing wear and tear replaced and the bathing facilities will be improved. So that service users are protected from potential staff who may do not follow good care practices or who may have a criminal record, the home’s recruitment and selection of staff process, must be effective and always followed. The home must receive; two references that describe the person’s abilities and qualities appropriate to the role they are to be employed, one of which must be from their last employer and a clear and current criminal records check. The manager must submit an application form to the Commission for Social Care Inspection (CSCI) so that she can be considered as the Registered Manager for this home. This is to make sure that the manager is “fit” to run the service in the best interests of the service users and to make sure that she Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 8 is aware of the laws related to running a home and the required standards that need to be maintained so that service users receive appropriate care. Although the manager maintained that correct fire procedures are carried out by the home, there was no evidence to prove this. The manager was advised on the importance of following the fire safety guidelines in the Fire Brigades Log Book so that the safety of the service users is protected. So that the health of the service users is also protected the cleanliness of the laundry must be improved. A discussion took place with the manager in relation to the quality assurance system the home has in place and how the outcomes could be used to develop the yearly Business Plan for the service. This will ensure that the service is developed and run in the best interests of the service users. 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 House DS0000059954.V298776.R01.S.doc Version 5.2 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 House DS0000059954.V298776.R01.S.doc Version 5.2 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): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A range of information is available which enables service users to make a fully informed choice about where they would like to live. The admissions process ensures that resident’s needs are assessed prior to care being offered. This helps to ensure that residents are offered the right type of care at the home. EVIDENCE: A Statement of Purpose and Service User Guide is in place to inform service users and other interested parties about the home and the services offered. These, along with other information about the home, are placed in a prominent position in the hallway of the home where service users and visitors can access them. Although service users are given a contract to be signed by themselves and the home that includes the full amount of fees charged, when examining one service user’s care file who moved into the home several months ago a Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 11 contract was not evident. This was brought to the attention of the manager who agreed to address it. The manager ensures that; an assessment of need and current care plan for the individual prospective service user is received from the referring agency, and that the home carries out their own assessment, prior to any service user being offered a place in the home. Once it is determined that individual needs can be met by the home the manager confirms this in writing to the service user. A date is then set for admission into the home. Examination of three case files confirmed that this process is carried out appropriately and as an outcome individual care plans are developed. This home does not provide intermediate care. Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager is currently making effective improvements to the care plan structure. They now guide staff in their care practices to appropriately address service users’ individual needs in a consistent way, while at the same time promoting their dignity and respecting their individual preferences. However staff do not always follow the correct procedures when recording the administration of medicines, therefore put residents at risk of harm EVIDENCE: Although all service users have a care plan, the manager is working hard to develop these into the new, more effective, care plan structure that are more effective in detail and identify the “area of care”, “the goal” to be achieved and the “intervention,” how it will be achieved. Records showed that each care plan is monitored monthly identifying improvements made, areas to be monitored or further work to be carried out. Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 13 Daily notes are kept for each resident that are appropriately used to develop the care plan. For example following advice given in relation to continence problems, the professional guidance given was included in the care plan for staff to follow in relation to how the service user should be supported regarding their continence needs. This home is not equipped to provide nursing care, however some service users do have clinical needs that are addressed by the Community Nurse Team. The home’s care files record dates and frequencies of when this takes place but the actual care plans relating to the nursing tasks are developed and monitored by the nurses and kept in the service users’ bedrooms. One service user currently stays in bed as a result of the deterioration of their medical condition and the care plan reflected the needs in relation to this. Risk assessments are in place regarding the risk of pressure sores developing, the use of bedsides, use of the hoist and eating and drinking. Risk assessments have been developed further and are now an integral part of the care plan. Having the care plan and risk assessments together gives continuity of the plan of care and directly gives staff access to any guidelines needed to reduce identified risks. The home has appropriate policies and procedures in place in relation to the administration of medication and all staff have now attended training in relation to this. The administration of the lunchtime medication was observed being appropriately carried out, however an anomaly was found when examining the medication records. Medication for one service user had been administered but not signed for. This was brought to the attention of the manager who was advised to use the appropriate spaces on the medication record supplied by the pharmacist, to record the date medication is received, the quantity received and who received it. Thorncliffe House DS0000059954.V298776.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Effective attempts are made by the manager and staff to offer a fulfilling lifestyle to service users within the home and the local community. Service users are offered a varied menu with wholesome food, which promotes their health and wellbeing. EVIDENCE: The home employs an activity coordinator who organises a range of activities inside and outside the home. A record is kept of all activities organised and who has taken part with appropriate comments on the success of the event. Service users were observed moving around the home independently and making choices regarding where they preferred to be and what they preferred to do. The communal areas around the home are arranged in a way so that service users have different areas where they can sit, join in activity, converse with others or take part in an individual activity. Two service users explained how they independently go into the local community one to buy their paper and another to go to the local library and bank. Staff and service users also discussed a planned outing to a local Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 15 seaside resort where they planned to have a day out with lunch in a nearby hotel. Comments in the home’s Comment Book, written by relatives of service users, confirmed the success of a recent Entertainment Evening that had taken place in the home. Another service user stated that, when the weather is good activity is planned in the attractive gardens where barbeques take place. The manager explained that some service users visit their families over the weekend and service users confirmed this. Families were observed visiting the home different times during the day and a service user remarked how they were always made to feel welcome. A meal was taken with service users that was nutritious and attractively served. Service users who needed assistance were supported sensitively and discreetly. Service users commented that there was always a choice of meals and that they were good. Thorncliffe House DS0000059954.V298776.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has comprehensive and accessible Complaints and Protection of Vulnerable Adult procedures that protect service users from abuse. However concerns that are taken by service users to the staff or the manager are not recorded, it could be concluded therefore that service users’ concerns are not taken seriously. EVIDENCE: Adequate procedures are in place in relation to making a complaint and a copy is issued to all service users and their families. Service users and relatives spoken to confirmed that they knew what to do if they were unhappy about the delivery of care, or other issues about the service provided. The home has not received or recorded any complaints since the last inspection, however there were several compliments from visitors recorded in the compliments book. A discussion took place with the manager in relation to concerns that are brought by service users to the manager or staff’s attention. Although service users may not want these to be recorded as formal complaints, it was suggested that they should be recorded with the outcome so that service users can see that concerns are taken seriously. All staff have now received training regarding the local authority’s adult protection procedures and a procedure file relating to these is available in the Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 17 office. During discussion with staff they were able to appropriately explain how they would respond if they witnessed abuse. Records relating to the service users’ finances were examined. It was evident service users or their families/representatives are supported and encouraged to manage their own financial affairs, however in the case where this does not happen the home has clear procedures and records that are accurate and kept up to date Thorncliffe House DS0000059954.V298776.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although improvements continue to be made to this home to provide a safe comfortable and clean environment for service users, the work is ongoing and will not be complete for some time yet. Currently the bathing facilities are inadequate and fail to give service users bathing choices. EVIDENCE: This service provides a homely environment that is tidy and generally clean. There are pleasant gardens and a patio area to the front of the building that are used effectively in good weather. There is a variety of garden furniture and a gazebo for service users to shade from the sun. The Victorian building is on three floors and these have been made accessible to service users by a shaft lift. There are however two bedrooms where service users must be able to access one flight of stairs independently. The Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 19 manager stated that only service users assessed as being physically able to manage the stairs without risk use these bedrooms. Previous inspections identified issues that needed to be addressed to improve the accessibility and general standards of the building. An improvement plan that was discussed and agreed with CSCI has been put into action and many areas of the building including some service users’ bedrooms have been decorated and refurbished to a good standard and a new boiler has been installed. However the planned extension to the building that was scheduled to start last month, has been put on hold due to the current lack of demand for residential places for older people in the area. This means that the structural work planned to improve the environment has not yet been carried out. Although this delay is understandable, some planned improvements now need to be addressed separately. The manager confirmed that that the plans to extend the ramp at the side of the house to the front entrance and to refurbish the yard and patio area are to go ahead. This will provide service users with easier access to the building and the gardens while also providing an additional attractive outside facility at the back of the house. There is a main road at the back of the house where buses run and cars can be parked, service users, their visitors and staff therefore use the back entrance. However, although the back entrance is more often used some visitors also approach the home from the front entrance. A discussion took place with the manager in relation to the security of this door and the image of the home this could portray. The manager agreed to address this. Some of the chairs and furnishings in the communal areas of the home are showing signs of wear and tear and should be renewed. These were brought to the attention of the manager. There are two bathrooms and only one is equipped with assisted bathing facilities. There are no shower rooms available for communal use. Staff confirmed that service users do not use the bathroom on the top floor, since no service user is able to bathe without support. This effectively reduces the number of accessible bathing facilities to one and so must be addressed. As stated in previous reports professional advice should be sought in relation to accessing the most appropriate bathing facilities regarding the needs of the service users, bearing in mind that a choice of bathing facilities should also be available. The laundry also needs to be refurbished; however a new washing machine and drier have recently been purchased. This ensures that soiled washing can be washed at the appropriate temperature to avoid the risk of infection. The waste bins in the laundry were dirty, as part of the control of infection procedures these must be kept clean. Thorncliffe House DS0000059954.V298776.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. An effective training schedule has meant that staff have the appropriate knowledge and skills to understand and meet service users’ needs and staffing levels are sufficient in number to be effective. However service users are put at risk as a result of the home not following appropriate recruitment procedures. EVIDENCE: Three care assistants, one a senior member of staff, the manager and several ancillary staff were on duty. This is an adequate number of staff to address the needs of the service users currently living at the home. An examination of the staff rotas proved that this number is consistent. The manager confirmed that there is little staff turnover and sickness does not present a problem. Observations of and discussions with staff confirmed that they have the necessary skills to meet the needs of the service users currently living at the home. All staff including the cooks have achieved at least NVQ level 2. Certificates in their files confirmed training achievements. Staff were observed to interact positively with service users who spoke in a complimentary way about staff attitudes and the level of care they provide. One family member visiting the home on the day of the inspection supported the service users’ views and said, “the staff are good and always there to assist when needed.” Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 21 The majority of staff that work at this home have done so for several years. Good and trusting relationships have therefore developed between staff and service users. A sample of staff files were examined that included those of a newly recruited member of staff and those of two members of staff employed occasionally to cover holidays and sickness. One file was not available and the others did not include all of the documents needed, including two references and current CRB checks. In the absence of such documents it is not certain that staff are suitable to work with vulnerable people, service users therefore could be put at risk. This was brought to the attention of the manager who agreed to address this important issue. Thorncliffe House DS0000059954.V298776.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager offers clear leadership and direction to the staff and this has resulted in a trained workforce that offers consistency of care and a home that is run in the best interests of the service users. However poor recruitment procedures recently followed have put service users at risk. EVIDENCE: The manager at this home has worked in care services for 12 years and has managed homes for several years and was the registered manager of the previous two homes. Although the manager has not yet submitted an application form to be considered as Registered Manager for this home, she confirmed that this would be completed within the next seven days. The manager also confirmed that Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 23 she has now started the Registered Managers Award and will be starting NVQ 4 in Care on its completion scheduled for December 2006. The manager was observed to work and interact with service users and staff both sensitively and professionally and staff confirmed that they liked her approach and felt they were being positively included in the running of the home. Service users also felt that they were kept informed of improvements and changes to be made. There is a Quality Monitoring System in place, and the Quality Monitoring File demonstrates how and when the weekly and monthly monitoring of different aspects of the service takes place. Service users surveys were also included. The manager confirmed that she is responsible for carrying this out. A discussion took place with the manager in relation to how the outcomes of this system and it was suggested that they could be used to develop the yearly Business Plan for the service. The manager was receptive to this idea. A fire log demonstrating up to date fire procedure practices was not available during the inspection but the manager confirmed that appropriate fire drills had taken place. The manager was advised on the importance of recording fire drills and checks of fire equipment accurately and it was suggested that she could delegate this responsibility to a senior member of staff. Thorncliffe House DS0000059954.V298776.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 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation 5 (1) Requirement Each service user must be provided with a Contract stating their terms and conditions with the home at the point of moving into the home. The Registered Person must ensure that staff administering medication adheres strictly to guidance issued by the Royal Pharmaceutical Society in respect of the safe receipt, administration and disposal of medicines in the home. Accurate records must be kept and a weekly audit system must be implemented by the Manager to monitor staff competence in this regard. 3 OP21 23 (2) OP19 Due to the extension of the building being put “on hold,” consideration must be given to the implications this may have on the timescales for the required improvements to the building and the CSCI must be informed of any changed plans. 31/07/06 Timescale for action 31/07/06 2 31/07/06 OP9 & OP37 13 (2), 17 (1 (a)) Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 26 The Registered Person must ensure that at appropriate places throughout the premises there are sufficient assisted bathing facilities. (08.06.05 & 30/04/06 Timescales not met.) 4 OP24 16(1)(2) The bedrooms not yet refurbished must be addressed and any furniture throughout the building that needs to be renewed or does not meet the needs of the service users must be replaced. (30/04/06 timescale not met) The laundry and the appliances must be kept clean and free from the risk of infection. Appropriate, robust recruitment procedures must be followed when recruiting staff to ensure that service users are not put at risk. Staff must not be employed before 2 references and a current CRB are received. The manager must submit an application form to the Commission for Social Care Inspection so that she is considered for Registration. (Timescale of 30/10/05 & 28/02/06 not met) The manager must successfully complete the Registered Managers Award and begin NVQ4 in Care. The home should carry out fire drills as suggested in the Fire Brigades Fire Precautions Log Book for example, for staff working night shift every three months and for staff working day shift every six months. The names of staff involved in the fire drills and instruction must be recorded and kept in the fire file so that the CSCI and Fire Service DS0000059954.V298776.R01.S.doc 31/12/06 5 6 OP26 & OP38 OP28 & OP29 13(3) 19 30/06/06 30/06/06 7 OP31 9 30/06/06 8 OP31 9(2)(i) 30/12/06 9. OP38 23(4) 30/06/06 Thorncliffe House Version 5.2 Page 27 if requested can inspect them. (28/02/06 Timescale not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4. Refer to Standard OP10 OP16 OP38 OP27 Good Practice Recommendations When a service user does not have a key to their bedroom door the reason should be recorded in the care plan. Concerns brought to the attention of staff or the manager should be recorded with the outcome. The names of staff and the dates they attended fire training and instruction took place should be included on a separate sheet in the fire file. 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.V298776.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thorncliffe House DS0000059954.V298776.R01.S.doc Version 5.2 Page 29 - 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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