Inspection on 28/07/05 for Thorndene

This inspection was carried out on 28th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Thorndene 04/06/07

Thorndene 13/12/05

Thorndene 21/02/05

Thorndene 01/09/04

Thorndene 02/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE THORNDENE 107 Thorne Road Doncaster South Yorkshire DN2 5BE Lead Inspector Valerie Hoyle 28 July 2005 09:00. 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 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. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Thorndene Address 107 Thorne Road Doncaster DN2 5BE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01302 327307 01302 327307 None Mr Gerald Pickup Mrs Kathleen Pickup PC Care Home only 22 Category(ies) of OP Old Age: 22 registration, with number of places THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total of 2 short stay places in the overall registration. Date of last inspection 21 February 2005 Brief Description of the Service: Thorndene is registered currently for twenty-two service users falling in the older persons category. There is a large conservatory to the rear of the building and a paved seating area and this is accessed via the dining area, and conservatory. The accommodation is a Victorian property, which is situated close to the centre of Doncaster within easy access of all facilities including shops.The homeowners Mr. and Mrs. Pickup are involved in the day-to-day operations of the home, and work to enhance service users experience of residential care. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours where a partial tour of the buildings was undertaken. The inspector examined three service users care plans and supporting documentation. Ten service users and six staff were spoken to during the visit. The inspector was able to speak to two relatives, and the hairdresser, to gain their views on how the home is run. What the service does well: What has improved since the last inspection? The registered manager has now obtained the required management qualification and also holds a nursing qualification, which ensures she has the qualities to effectively manage the home. The staff holds the required accredited medication qualification and have met the outstanding requirement from the previous inspection. The staff at the home have recently achieved a quality kite mark ‘Investors In People’ that is recognition of their investment in training and developing the work force. The management and staff are commended for their efforts in achieving this award THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 6 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. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 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 standard(s) 3, 4, 5. Service users are not admitted into the home without a full needs assessment undertaken by the registered manager, to ensure their needs are met by a well trained staff team. Service users can visit the home prior to their admission to assess if they want to live there. EVIDENCE: The placing authority provides information to the home prior to admission and the registered manager is able to make an initial judgement about the suitability of the service user, and assess if the staff are able to meet their care needs. Four assessment documents examined included sufficient information to ensure care needs can be met by the staff at the home. One service user was able to confirm that she/he was visited prior to admission, and said the staff were very good and were able to meet her/his needs. Another service user said that she/he wished that she/he had made the decision to live at Thorndene years before but did not realise how good the home was. Staff have the required skills and knowledge to ensure service users are well cared for. Staff said that they enjoyed working at the home. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10. The care planning systems are sufficiently detailed to enable staff to deliver the care to service users who have specific identified needs. Arrangements for dealing with service users health issues are adequately met by staff at the home, with support from health professionals. Medication policies and procedures are well managed and staff have the necessary skills to administer the medication to service users, ensuring their safety and protection. Staff have the necessary skills and knowledge to ensure service users are treated with respect and dignity. EVIDENCE: Three care plans examined and these were comprehensively written with clear methods of staff intervention. There is sufficient evidence to confirm staff on a regular basis reviews the care plans and comprehensive risk assessments ensure service users can maintain their independence while remaining in a safe environment. Staff are comfortable with their abilities to meet the needs of service users and they are well informed and trained to deliver the care. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 10 Records examined and discussion with the staff confirmed service users healthcare needs are met. District nurses give advice and support staff to ensures service users healthcare needs are met. Service users are escorted to medical appointments by staff and comprehensive records are completed ensuring information is shared with those who care for the individual. An audit of medication stocks and records was examined and were found to be correct ensuring the health and safety of service users. All senior carers have undertaken accredited medication training to ensure they have the required skills and knowledge. There were many examples of good practise by staff and on many occasions there were good interactions between staff and service users and the visiting relatives. Most service users were referred to by their first name and this was with the approval of users, and was also stated in their care plan. One service users said that she/he chose to live at Thorndene and would not consider living anywhere else. Service users spoke fondly about the registered providers saying that they were very kind and always sorted things out for them. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15. Social activities are arranged by the home and service users are able to participate if they wish, to enhance their lifestyle experience. Mealtimes are well managed and the facilities promote a calm environment with a pleasant dining area to accommodate all service users. The home has clear visiting policies and procedures to ensure service users can maintain contact with their family and friends. EVIDENCE: There is a lively atmosphere at the home and service users choose where and with whom they want to spend their time. The conservatory is an area used by service users who enjoy a quieter area and the service users chatted about life at the home, and the friendships they have developed. The visiting hairdresser users this area and she said the home is well run and staff are always helpful. Visiting relatives said they were always made to feel welcome and staff were very caring. The staff at the home encourages relatives to play an active part in the home and they are invited to social events and outings. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 12 The menus are well balanced with a good choice for each meal. Mealtimes were observed and the food looked good quality and was well presented. Staff were available throughout the meal and were able to give assistance where needed, they appeared to be unhurried and had time to chat to service users. Service users said the meals were very nice with a good variety and a number of service users said the chef was excellent and spent time chatting to them about the food and how he liked to do fancy cakes and sweets. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18. Service users and their relatives are provided information to enable them the raise concerns about the home and their care. Adult protection Policies, procedures and training of staff ensure the protection of service users from abuse. EVIDENCE: There is a complaints procedure that is available to service users and visitors. The procedure is also referred to in the service users guide, identifying the stages to follow; this includes the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection is included in the procedure. There is a comprehensive Adult Abuse and Whistleblowing and staff follow the procedures to those standards. The registered manager would investigate fully any allegations of abuse and would follow the necessary procedures if any were substantiated. The registered manager holds discussions with staff to talk over issues and how to recognise different forms of abuse. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 26. The registered provider continues to improve the décor and furnishings at the home creating comfortable and safe environments for service users. The home is clean and free from odours and there is sufficient domestic staff to maintain good hygiene standards. EVIDENCE: The registered providers continue to make improvement to the fabrics and furnishings at the home. The home is situated close to the town centre of Doncaster and has lawned gardens to the rear of the building. The registered providers have created a paved seating area to the side of the building and this area has colourful plants and parasols to ensure sufficient shade is provided for those who choose to spend time in the gardens. The home was clean and free from offensive odours and service users said that their bedroom was always kept clean and tidy. The domestic staff are commended for their efforts in maintaining the cleanliness of the home. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Staff have the skills and knowledge to fulfil their roles within the home, and a stable staff group ensures continuity of care by staff that knows the service users. Recruitment policies are followed ensuring the safety and protection of service users. EVIDENCE: Staff rotas examined demonstrated there is sufficient staff to meet the needs of service users. Training in a number of areas has been undertaken since the last inspection. There is a comprehensive induction programme and a number was examined. One new member of staff said that she had commenced her induction and felt confident in her role as care assistant. Staff continues to work towards attaining NVQ qualification although they do not meet the requirement of 50 NVQ qualified staff. The registered manager is hoping that most staff will obtain the qualification by the end of the year. A number of staff of new staff have been employed at the home since the last inspection, to improve the staffing ratios from two to three during the day. This enables staff to spend more time developing activity programmes for service users. The registered manager follows recruitment procedures to ensure the safety and protection of service users. One new member of staff confirmed that she commenced employment following a CRB check and satisfactory references being obtained. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 38. The registered manager is skilled and experienced to manage the home to ensure the safety and protection of the service users. Staff and service users follow health and safety procedures and records provide evidence of servicing of essential equipment EVIDENCE: The registered manager has a wealth of experience and knowledge and is able to demonstrate her ability to manage the home. She holds the required management and care qualifications and she is also a qualified nurse. She operates an open door policy to ensure she is accessible to staff and service users. Service users spoke highly of the manager and said she was very caring. Staff and group meetings ensure that staff are informed about training opportunities and the day to day running of the home, they are also encouraged to be involved in decision making. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 17 Accident reports are analysed by the manager to ensure risk assessments are developed where required. Maintenance and service records examined were up to date and current to the services provided. The manager has the required Health and Safety policies and procedures and displays the relevant notices. Fire safety procedures are in place and service records were examined and were current, ensuring the safety of service users. THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 x x x x x x 3 THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 19 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 Regulation Requirement Timescale for action 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 OP28 Good Practice Recommendations The home must work towards providing a minimum of 50 of staff who are NVQ level 2 qualified in 2005 THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection First Floor, Barclay Court Heavens Walk Doncaster DN4 5HZ 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 THORNDENE J55-J07 S7967 Thorndene V190094 270705 Stage 4.doc Version 1.40 Page 21 - 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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