CARE HOMES FOR OLDER PEOPLE
Thorncliffe House 15 Thornhill Park Sunderland SR2 7LA Lead Inspector
Mrs Elsie Allnutt Unannounced Inspection 6th September 2005 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.V250068.R01.S.doc Version 5.0 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.V250068.R01.S.doc Version 5.0 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.V250068.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th November 2004 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. 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 serivice users. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in September 2005 and took 7 hours. Time was spent talking to service users, visitors and staff during which time their views of the service were sought, all indicated that they were satisfied with the service provided. A tour of the building was made as well as an examination of a number of records and a midday meal was taken with service users. What the service does well: What has improved since the last inspection?
Many of the requirements and recommendations of the last report have been addressed and in doing so many improvements have been made to this service both in relation to the environment and the administrative systems. Some service users commented on how nice the lounge and dining room were since they had been painted. They commented that the new curtains and small furnishings added to the brighter look. Some bedrooms have also been decorated and refurbished resulting in brighter and lighter environments for the service users. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 6 An effective training programme has equipped staff with the skills necessary for their individual roles. There are now 90 staff qualified in NVQ. Other training carried out since the last inspection includes mandatory training and distant learning courses in health and safety and infection control. The standard of care being delivered and observed on the day of the inspection reflected the hard work that has been carried out by staff in relation to training. So that service users are protected, the home’s recruitment policies and procedures have been reviewed and revised, so that vigorous procedures take place during the recruitment process. Detailed information in relation to the individual needs of the service users is now recorded in the care plan and staff are guided in relation to how their needs should be met whilst promoting individuals’ independence. The home has recently developed a policy that addresses service users wishes in relation to dealing with growing older, terminal illness and death and this is now recorded as part of the care plan so that service users’ wishes are addressed and followed at the appropriate time. So that service users rights are protected care plans, as well as other personal information, are now stored in secure facilities in the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 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.V250068.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 The home provides the necessary information to make an informed choice about where to live and service users are admitted to the home with a comprehensive preadmission assessment, a contract and an opportunity to experience life in the home prior to moving in. This home is not equipped for and does not provide intermediate care. EVIDENCE: The home has now developed a comprehensive Statement of Purpose and Service User Guide, they are both well set out and the latter is made accessible to service users with the use of photographs. Minor discrepancies were discussed and plans were put in place to address them. Of the care files sampled all had Contracts that outlined the terms and conditions of the service provided. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 9 Preadmission assessments and care plans from the referring agency were in place and the care plans sampled that were developed by the home reflected the assessed needs of the service users. Introductory visits by service users prior to admission were documented in the care plans with comments in relation to their response. There was also a written comment by the manager whether the home could meet their needs. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 11 While respecting the privacy and dignity of the service users their healthcare needs are well met, however these could be recorded in a more structured way. Staff are trained to administer medication in a way that promotes the safety of service users. EVIDENCE: Although the necessary information in relation to the service users’ health needs was evident, discussion took place with the manager in relation to how different areas of the care plan could be more appropriately structured and as a result made more accessible. Staff demonstrated a good understanding of the needs of the individual service users and confirmed that they attended training in relation to different health care needs, however training in relation to dementia care still needs to be organised. Some service users confirmed that their needs were adequately met. So that staff deliver consistent care, guidelines in relation to different aspects of their care needs are in place, for example, how a service user likes to be
Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 11 bathed and the level of assistance they need as well as the preference to which gender of staff they prefer. Risk assessments with risk management plans are appropriately in place, for example for a person at risk of developing pressure sores guidelines in relation to using a pressure cushion and the direction of the community nurse are in place. Risk assessments are also in place in relation to the administration of medication. All staff have now attended training in relation to the administration and although a full audit of medication was not carried out on this occasion, the process of the administration of the medication during the lunchtime period was observed to be carried out appropriately. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Service users are offered the opportunity of participating in a range of leisure and social activities enabling them to lead active and fulfilled lives, and are offered a choice of nutritious meals, to help promote their health and general well being. 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. A discussion took place with the manager in relation to how this important information could be developed and included in the individual care files. Service users discussed activities they had enjoyed and the places they had visited for example Beamish, Washington Old Hall and Sunderland Glass Centre. Service users also discussed the activities they enjoyed doing before moving to the home and which they have continued now living at Thorncliffe House, for example going to the town shopping independently, going out to pick up their daily newspaper and going to put a bet on the horses.
Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 13 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 two different family members remarked how they were always made to feel welcome. A meal was taken with service users, this 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.V250068.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has comprehensive and accessible Complaints and POVA procedures that protects service users from abuse, however so that all staff are fully aware of the local authority’s adult protection procedures a copy must be accessible within the home. 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 confirmed that they knew what to do if they were unhappy about something. The home has not received any complaints since the last inspection, however there were several compliments from visitors recorded in the compliments book. Effort has been made for staff to access training in relation to the local authority’s adult protection procedures known as MAPPVA (the Multi Agency for the Protection Panel of Vulnerable Adults.) However not all staff have accessed this training as yet, nor has the home accessed a copy of the MAPPVA Procedure File. A discussion took place with the manager in relation to how to access a copy. When discussed with staff they were able to appropriately explain how they would respond if they witnessed abuse. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 26 Although many improvements have been 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: The home is currently addressing the many issues raised at the last inspection in relation to the improvements needed to make the building more accessible and of an improved standard. The proprietor discussed his plans to build an extension on to the home to provide accommodation for a further five service users. The architect’s plans are currently with the local planning department seeking approval. The need to improve accessibility into the home is also to be addressed, along with further refurbishment plans to improve the overall standard of the existing building. This includes improving the bathing facilities and giving
Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 16 service users more choice in this area, as well as the special appliances they may need. Many areas of the home, including some bedrooms, have been decorated since the last inspection providing a brighter and more attractive environment for service users to live. There are plans to refurbish all of the bedrooms before the extension to the building is started. Currently there is a shaft lift to access the second and third floors, however there are second landings that are accessed by two or three steps where service users with bedrooms in these areas need to have good mobility. On the day of inspection the home was clean and tidy, and service users and their families were observed enjoying the good weather having tea and biscuits out on the elevated patio to the front of the building. So that everyone is kept informed of the plans for this service, there was an artist’s impression on the wall in the hallway, of the proposed extension and refurbishments to take place, for service users, staff and visitors to see and comment on. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29, 30 Satisfactory staffing levels, recruitment procedures and staff training all contribute to service users needs being met and remaining safe in the home. 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 in the home. An inspection of the staff rotas proved that this number is consistent. 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. Although satisfactory recruitment procedures are now in place and staff have job descriptions appropriate to their role, the recruitment procedures were not evidenced as no new staff have been employed over the past 10 months since the new manager was appointed and the new procedures were in place. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 18 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, 34, 35, 37, 38 The home’s policies and procedures and care practices which are in place protect and promotes the health and safety of the service users. The manager offers clear leadership and direction to the staff and this has resulted in a trained workforce that offers consistency of care to service users. EVIDENCE: A new manager has been appointed since the last inspection who previous to this appointment was a registered manager at another similar establishment. She is systematically addressing the issues raised in the previous inspection report. The manager has had many years experience working in care in a senior role and is currently working towards the Registered Managers Award and NVQ 4 in Care. Although a full audit of individual service users’ finances did not take place records were in place that demonstrated service users monies were kept
Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 19 individually along with receipts of any transactions. All transactions were recorded and signed by two members of staff. A certificate on display in the home confirmed that the proprietor has taken out appropriate insurance cover sufficient to cover his legal liabilities to service users staff and third parties. Although the plans to further develop the service were evident the business and financial plan for the service were not available on this occasion. The fire log and accident book were examined and were satisfactory, however the manager was advised to record all staff fire training and instruction on a separate sheet in the fire file with the date and names of those who had attended. The manager was receptive to this idea. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 20 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 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 2 X 2 X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X 2 3 X 3 3 Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 21 Yes 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 OP8OP30 Regulation 12(1) Requirement Timescale for action 30/12/05 2 OP18 13 (6) 3 OP19OP22 23 (2) 23 (2)(n)(o) 4 OP21 23 (2)(j) Staff must receive training in relation to dementia needs so that the health and social needs of service users with dementia are fully met. All staff must be trained in the 30/12/05 local authoritys POVA (MAPPVA ) procedures and so that staff have guidance in them, a copy of the procedures file must be available in the home. In line with the requirements of 30/12/05 the Disability Discrimination Act, the home’s physical environment should be reviewed in consultation with Service Users and relevant professionals to consider whether access and facilities can be improved for existing Service Users who experience mobility difficulties.(This should have been carried out prior to October 31st 2004). The Registered Person must 30/12/05 ensure that at appropriate places throughout the premises there are sufficient assisted bathing facilities. (08.06.05 Timescale
DS0000059954.V250068.R01.S.doc Version 5.0 Thorncliffe House Page 22 5 6 OP24 OP31 16(1)(2) 9 7 OP31 9(2)(i) 8 OP34 25 (1) not met.) The bedrooms not yet refurbished must be addressed. The manager must submit an application form to the Commission for Social Care Inspection so that she is considered for Registration. The manager must successfully complete the Registered Managers Award and NVQ4 in Care. A copy of the home’s current business and financial plan must be made available for inspection.(08.03.05 Timescale not met.) 30/12/05 30/10/05 30/12/05 30/12/05 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 Refer to Standard OP1 OP7 OP38 Good Practice Recommendations The minor adjustments to the Statement of Purpose and the Service User Guide should be made. The care plans should be developed into different sections so that they are more easily accessible. The names of staff and the dates they attended when fire training and instruction took place should be included on a separate sheet in the fire file. Thorncliffe House DS0000059954.V250068.R01.S.doc Version 5.0 Page 23 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
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