Inspection on 04/06/07 for Thorndene

This inspection was carried out on 4th June 2007.

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

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

Other inspections for this house

Thorndene 13/12/05

Thorndene 28/07/05

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 DN2 5BE Lead Inspector Gillian Sample Key Unannounced Inspection 10:15 4th June 2007 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 Thorndene DS0000007967.V329322.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. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thorndene Address 107 Thorne Road Doncaster DN2 5BE 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) 01302 327307 01302 327307 NONE Mr Gerald Pickup Mrs Kathleen Pickup Mrs Kathleen Pickup Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total of 2 short-stay places within the overall registration. Date of last inspection 13th December 2005 Brief Description of the Service: Thorndene is registered currently for twenty two people over 65 years of age. The registered providers and their staff provide accommodation, personal care, catering, laundry and domestic services. The home is owned by Mr Gerald and Mrs Kathleen Pickup. Mrs Pickup also acts as manager of the home. The building is a large Victorian property, which has been converted and extended to provide living, dining and bedroom accommodation with bathroom kitchen and toilet facilities. People living at the home have access to all floors via the passenger lift. The home is close to the centre of Doncaster with access to the town’s facilities and shops. Information about the service is given to new and existing service users to the home detailing the accommodation, facilities and services provided. In May 2007, the weekly fee was quoted by the providers as being £375.00 per week. Additional charges not covered by the fee are private chiropody costing £7.50, hairdressing, newspapers and magazines at cost price, and personal transport such as taxi fares at cost price. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: ● ● ● ● ● Reviewing information, which has been received about the home since the last inspection Information provided by the manager on a pre-inspection questionnaire Comment cards returned from people living at the home Comment cards returned from staff working at the home A visit to the home on 4th June 2007 The visit to the home lasted just less than five hours. The inspector spoke to people who live at the home, the Deputy Manager and staff on duty. Records relating to people living there, staff and the management activities of the home were inspected. Care practices and routines of the home were seen. This helped the inspector to gain an insight into what life is like at Thorndene for the people who live there. The Deputy Manager, Natalie Tucker, and Mr and Mrs Pickup, the owners, assisted the inspector and Mr Pickup and the Deputy Manager were given verbal feedback at the end of the inspection. What the service does well: The service provides a homely and welcoming atmosphere to people. The care provided at the home is aimed to ensure that residents are in control of their own lives as far as possible. Personal and health care is provided in a way, which is sensitive to people’s dignity and privacy. People had positive comments to make about the home, its staff and the services it provides. Comments about staff were “they’re lovely girls”. The home is clean and comfortable with a pleasant atmosphere. Visitors commented that the home is “always fresh and tidy”. The home is managed in a way, which enables people to contribute to the way in which the service is delivered and they have opportunities to influence the way their care is provided. There are systems in place, which identify potential improvements to the service, which are then carried out. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply People who use the service experience excellent quality outcomes in this area. They can be assured that they will have chance to experience the service and that their needs will be assessed prior to coming to live at the home. We have made this judgement using a range of evidence, including a visit to this service. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 9 EVIDENCE: Care records examined showed that information had been gathered about prospective service users and an assessment made of their needs. Where information had been supplied by a purchasing local authority, this information was used as a basis to make a detailed assessment and develop a plan of care to ensure individuals’ needs would be met. In all files examined, the initial assessment had been more fully developed within days of the service user moving into the home. Individual preferences were recorded for the way people wished to have their care delivered. One person had been admitted to the home only a few days previously, and their care plan noted sufficient details for care staff to provide good quality care. Another person said that they had visited the home prior to moving in. Written surveys returned said that people had enough information about the home so they could decide whether it was the right place for them. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience excellent quality outcomes in this area. People have their personal and health care needs met by staff who work in a way which promotes dignity, respect and independence. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The three care plans seen reflected individual needs and had comprehensive information about the personal history, individual choices and preferences of people at the home. Records were maintained on a daily basis detailing their changing needs and the care provided. Any risks associated with providing care were also recorded, such as the risk of falling or the development of pressure sores. People said that they had been consulted over whether they had any objection to their care being provided by a male carer. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 11 The health care needs, and the involvement of any health care professionals, was recorded. Two community nursing staff spoken with said that the care at the home was responsive to people’s changing health needs and that staff asked for advice or attention when they had identified problems. Comments were “personal care is second to none.” “What I’ve seen of the home and care, it’s excellent.” Some good practice was seen during the visit. Staff responded promptly and sensitively to a person who had fallen in their room and needed assistance. During lunch, staff assisted people to eat with exclusive and unhurried attention. Staff were seen relating to people with respect. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. Daily life and social activities offer service users opportunities to live their preferred lifestyle, contribute to their own and others lives within the home, and retain relationships in the wider community. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During the visit, people were seen spending time as they wished: some sat in their own rooms and others spent time in the dining room or conservatory. One person said “I like sitting here (in the conservatory) where you can see what’s going on.” Pre-inspection information supplied showed that a number of physical, social and leisure activities are available to people living at the home. Organised trips outside the home are provided when these can be financed by a residents’ fund with money raised by events such as coffee mornings. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 13 Lunch was seen being prepared and served. The meal looked and smelt appetising and the main course was served with three vegetables. People spoken with said they enjoyed the food. People who needed assistance with their meal were helped in a sensitive way, which preserved their dignity. The chef demonstrated knowledge of people’s likes and dislikes and paid attention to this during service of the meal. Trays for people eating in their own rooms were well presented. The chef bakes cakes and pastries to serve at tea and other times of the day and people praised the standard of his baking and cooking. People choose what they would like to eat from a daily menu, which is presented to them each morning. People said they had opportunities to spend time outside the home and some were seen going out for a walk. People received visitors during the day spent at the home. They also said they had formed friendships with other people living there. One said “we just hit it off and spend quite a bit of time together.” Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. Service users are able to make a complaint using information provided by the home and are protected by the awareness of staff of potential abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a complaints policy and procedure that is detailed in the Service User Guide to the home, available to people who live or are interested in living at the home. No complaint had been recorded since the last key inspection. The procedure sets out timescales for initial response, investigation and reporting the outcome to any complainant. Written surveys returned said that people knew how to make a complaint. People spoken with said they would speak to Mrs Pickup or her deputy if they were unhappy about any aspect of their service. The home has a policy on how the service will protect vulnerable adults and a copy of the local authority’s procedure is available to the manager and staff. Staff training records showed that the majority of staff have been trained in abuse and its prevention. A whistle blowing policy is in place so that staff can report bad practice without fear of being victimised. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience excellent quality outcomes in this area. They can be assured that the home is a clean and pleasant place, which is properly maintained to a high level of comfort and safety. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: All floors of the home were seen including some bedrooms, bathroom and toilet facilities, the sitting and dining areas and the kitchen and laundry facilities. All areas seen were clean and free from unpleasant odours. Written surveys returned said that the home was always kept fresh and clean. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 16 The home is well maintained and is decorated in a homely style. Outside areas are well maintained with sitting areas and mature plants. There was evidence that the building was being properly maintained inside and outside. Mr Pickup described plans to improve outside areas at the back of the property to provide people with an additional accessible garden area. There are also plans to provide an additional bedroom and bathroom on the first floor by demolishing the existing conservatory and building a new conservatory with the new accommodation above. Mr Pickup said the building work for this would not start until autumn so that people living at the home would have the use of the conservatory and outside space during the summer. Pre inspection information provided showed the visits made by local fire and environmental health authorities and the action taken by the manager based on their recommendations. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. Recruitment processes are in place aimed to ensure that potential staff are properly checked as being suitable to work with vulnerable adults. Service users are given help by staff who are properly trained and have their practice monitored. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Recruitment processes were checked by looking at three staff files. These showed that employment at the home is dependent on an applicant making written application. Checks made of applicants include taking up three written references and a criminal records disclosure prior to interview and subsequent appointment. On one of the three files seen, one did not contain a criminal records disclosure. This was checked by Mrs Pickup and the Deputy Manager who said this had been missed. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 18 Staff are employed in sufficient numbers to provide the level of support, which people need during the day and at night. Observation at the visit showed that staff are available to deal with the needs of people living at the home: there was a prompt response when a resident fell, staff were available on a one to one basis to help people eat. Written comments from care staff said that they had adequate time to look after people living at the home. Information supplied prior to the visit showed that 54 of staff have achieved an NVQ level 2 in care, which currently meets the standard. Staff are trained in mandatory health and safety topics on a rolling programme, and are also able to train in subjects pertinent to their work, such as communication. People said that the staff were approachable and friendly. One survey said “I have only been (here) for a week or two but I have found in that time I have received every consideration.” Written comments from residents said that staff listened to them and were usually available to them. Health care staff spoken with said that the care provided was “second to none”. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience excellent quality outcomes in this area. They can be assured that their views will be sought and acted upon and that the service will be managed in their best interests. Systems in place at the home ensure that the health and safety of service users is being properly addressed. We have made this judgement using a range of evidence, including a visit to this service. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 20 EVIDENCE: Mrs Kathleen Pickup is the joint owner and acts as manager of the home. She holds the required management and care qualifications and she is also a qualified nurse. She manages the day to day operation of the home with the support of a Deputy Manager and has experience and knowledge of providing care for older people. The Deputy Manager, Natalie Tucker, is undertaking the Registered Managers Award. Written questionnaires from staff said “I believe that relations between staff and the managers/owners is very good”. A quality assurance system is in place based on the views of service users, their relatives and staff. Analysis of the 2006 survey was given to the inspector. This document highlighted aspects of the service being tested and results within these areas so that any shortfall could be identified and dealt with. People spoken with were aware of the proposed changes to the conservatory area of the home and welcomed the improvement. One said “It will be easier to get to the back garden once its finished.” “It will have a proper roof so it should keep cooler.” There are regular residents’ meeting so that people can make suggestions about the service. Systems are in place so that service users’ money and valuables are handled in a proper way. Pre inspection information confirmed that the home does not deal with any monies of behalf of people living there. All bedrooms seen had a lockable space in which to keep money or anything valuable. Pre inspection information supplied showed that records are maintained as required by legislation. The home’s fire records were seen which included checks on fire detection and prevention equipment, emergency lighting, staff fire training and drills. All these were up to date. Accident records had been analysed so that action can be taken to prevent further accident or injury to people. Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Schedule 2 Requirement A criminal records disclosure at enhanced level must be obtained on the staff member identified at the visit to the service. Timescale for action 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thorndene DS0000007967.V329322.R01.S.doc Version 5.2 Page 24 - 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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