Inspection on 08/11/07 for Thornebury Nursing Home

This inspection was carried out on 8th November 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thornebury Nursing Home 25/01/07

Thornebury Nursing Home 28/02/06

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Thornebury Nursing Home 5,7 &9 Langthorne Road Leytonstone London E11 4HL Lead Inspector Stanley Phipps Unannounced Inspection 8th November 2007 12:00 Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 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 Thornebury Nursing Home DS0000065852.V354229.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 Adults 18-65. 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. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornebury Nursing Home Address 5,7 &9 Langthorne Road Leytonstone London E11 4HL 020 8539 9443 020 8539 9443 helens@outlookcare.org.uk 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) Outlook Care Helen Samangan Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2007 Brief Description of the Service: Thornebury Nursing Home is registered to provide care for up to 16 service users of either sex who have enduring mental health problems. The aim of the home is to provide rehabilitation and to enable service users to move to more independent living facilities. For the majority of residents this is a long-term aim. The building is comprised of three two-storey buildings, which have been adapted and converted to provide single rooms and communal areas for service users and office space for staff. The home is situated in a residential area of Leytonstone with easy access to local facilities and public transport. The home is adapted for wheelchair users and those with limited mobility, including four of the bedrooms. A statement of purpose is made available to all service users in the home and is kept in the main Office. A service user guide is also given to each service user upon admission to the home. Fees for the services provided range from £810.28 to £1,045.00. Service users have to pay extra for personal effects such as toiletries and clothing – the prices of which are variable. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on the 08/11/07. It was unannounced and a key inspection of the service, which meant that all the key minimum standards for ‘Younger Adults’ were assessed. The assessment also considered information provided in the Annual Quality Assurance Assessment (AQAA) by the registered persons. An assessment of policies and procedures, medication practice, activities, menus, all records required by regulation, service user plans and the environment was undertaken. Over the course of the inspection discussions were held with several staff, three service users, senior staff members and the registered manager. The inspection also considered comment cards completed by staff, service users alongside verbal feedback that was provided by external professionals and relatives. The inspection found that service users living at Thornebury Nursing Home were receiving a good standard of care, which could be attributed to the compliance with the national minimum standards and its associated regulations and the all requirements made in the last inspection report. It must be stated that the service users and staff made a significant contribution to the inspection process for which the Commission is grateful. In concluding it was positive to see that the organisation has been doing some thinking around equality and diversity as there is a very mixed client group at Thornebury Nursing Home. To this end plans were in place to: implement the recommendations and outcomes of the draft diversity procedures, organise initially, two gender groups to look at gender specific issues, and consult with the service users about using the quiet room for prayers. This direction of travel would have a positive impact on the outcomes for service users, which is positive. What the service does well: The service user guide is well–illustrated, involves service users and is in a format that they could relate to. Service users continue to enjoy a wide range of activities – something that most of them look forward to. This is clearly evidenced throughout the home with pictures of events lining the walls of the home. Service users get to experience a taste of religious and other cultural festivities such as Africa and Valentines Day, Halloween and Christmas. The management and staff work well towards in supporting service users to engage in day facilities that are specific to their needs. Two good examples are attendance at an African – Caribbean and a specialist physiotherapy group. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 6 Meals are diverse, specific and efforts are made to engage service users in this process, making it an enjoyable activity. As well as keeping complaints, the home maintains a record of compliments, which is positive. The home is roomy, yet homely and this allow service users to have options depending on their mood and choice. The organisation has a good training and development plan for its staff, which would ensure that service users continue to receive a good standard of care and support while living at Thornebury Nursing Home. The registered persons have demonstrated willingness in working with the Commission to ensure positive outcomes for service users. What has improved since the last inspection? What they could do better: Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 7 Ensure that food is appropriately stored at all times. 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. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (1,2) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users have updated information, which they could rely on in making a decision to live at Thornebury Nursing Home. Their needs are assessed in detail prior to admission to determine the suitability of the home in meeting them. EVIDENCE: An updated statement of purpose and service user guide is in place at the home and available to both current and prospective service users. Both documents were in line with the national minimum standards (YA1) and the Care Homes Regulations 2001 (Regulations. 4&5). The documents are informative and the service user guide is very illustrative, making it an attraction for the service users. Service users are a part of this document for which their consent was sought. Although the beds are blocked purchased via the Waltham Forest Accommodation Panel, feedback from most service users indicated that they had good information about the home prior to choosing to live at Thornebury Nursing Home. This is positive. The assessment details of the most recently admitted service user was examined and were quite detailed. It was observed that there is a clear pathway to gain admission to the service. This includes having a detailed referral and assessment protocol, which looks at all aspects of an individual in determining whether the service users needs could be met by the home. As a Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 10 matter of course, copies of CPA, psychiatric and social worker reports are obtained prior to the home carrying out its own assessment. The assessment is usually carried out by two care managers and involves the service user and/or their relatives. Prior to the assessment a copy of the service user guide is made available to the prospective service user. This ensures that he/she has as much information as possible before making a decision to live at Thornebury Nursing Home. It was clear that the home’s admissions process is thorough and set up to ensure that only service users that meet their eligibility criteria would be admitted to the home. At the time of the visit consideration was being given to restructuring the assessment form with a view to enhancing the process of gathering information. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,8,9) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users have the benefit of a comprehensive plan that is developed with their needs in mind. Improvements in the frequencies of meeting service users ensure that they achieve their individual objectives. This involves taking risks within an improved risk management framework to ensure that their safety and independence is promoted. EVIDENCE: A random sample of three service users’ files was examined and in each case a service user plan was in place for the individuals concerned. In one case there was evidence that the home had embarked upon person centred planning, which puts the needs and aspirations of the individual to the front of how the service is delivered to them. The plans seen were updated and regularly evaluated and it was clear that service users were involved in the process of planning their care. Two service users spoken to informed that they are pleased with the current format of their individual plans. From discussions held with the management and individual members of staff, they were clear about the importance of supporting service users to take control of their lives and so information is made readily available to them. A Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 12 good example of this was where ‘The Mental Capacity Act’ placed on the service users’ notice board. More importantly it was in an easy read format, which would not only make easier to digest, but also reach a wider audience. Each service user has an allocated key worker who is responsible for coordinating their care and support needs in the home. They also monitor the service users’ progress and this is fed into multi-disciplinary reviews and meetings to ensure that they get the best possible outcomes from such meetings. There was evidence that key worker meetings were more frequent than previously identified and this is positive. All service users spoken to knew their key worker by name and were happy to have an association with them. Service users meetings were regularly held as this allows them to make contributions to how the service is run. They are held weekly and the outcomes impact on the daily operation of the service. The topics are very much rolling items such as activities, holidays, health and safety and meals, with the responsibility for taking minutes – shared between service users and the staff. It was noted that action has been taken as recommended to print the named of the person taking the minutes to promote transparency and accountability. Risk assessments were in place for each service user and they were linked to their individual plans. They were updated and there was evidence that they were regularly reviewed. From the documentation seen it was also clear that the main aim of undertaking the risk assessment was to promote service users’ independence within a safe framework. Service users with the objective of moving on to more independent living felt that risk assessments and risk management was a useful tool in getting to that point. Examples of key areas were using the kitchen independently and handling medication independently. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12,13,15,16,17) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users are enabled to participate in their community as far as possible. They also enjoy a range of activities and, are able to maintain and develop social and personal networks of their choosing. They are supported to exercise their rights, which are respected and promoted by staff in the home. Service users also enjoy a variety of meals that meet their cultural and nutritional needs. EVIDENCE: Service users are involved in a wide range of activities both internally and externally. They enjoy both one-to –one and group sessions and a weekly activity planner is place. Despite this, there is a fair amount of flexibility in terms of participation, while in extreme cases the level of participation is minimal. However, all service users have opportunities for engagement in activities of their choice and personal interests. Some of the internal activities include; arts and crafts, relaxation, keep fit, a reading group and an art group. All service users spoken to expressed a high level of satisfaction with the level and quality of activities that are provided in the home. Feedback from staff indicated that they would like to work with service users to increasing the level Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 14 of activities in the home, which is positive. It was noted that service users went on a five-day holiday to Butlins earlier this year, which they reportedly enjoyed. Another went with his parents for up to two weeks, while five individual went on a canal boat on the 13/7/07 for a new experience. There was good evidence to confirm that service users are integrated into their community. Two individuals attend Community Day Centres up to twice per week, while others access the community independently. They visit the local cafes and some even attend the internet café. Service users also go shopping, cinema, bowling, for meals out and day trips. It is reported that up three service users have acquired their London Taxi Cards and all have a freedom pass. Service users therefore not only have the means but also the support to widely use the community, which is positive. A visiting policy is in place to enable service users to maintain links with their friends and families. It is recognised that some individuals have more input than others and staff are well aware of this. Relatives are encouraged to participate in promoting the welfare of individual service users and up to three individuals have such input. Another service user visits his family every weekend, while others enjoy overnight stays at various intervals. It was clear that service users are given appropriate support and opportunities to maintain relationships with their friends and families. From observation during the inspection, staff were observed in the treating service users with dignity and respect. One hundred per cent of the feedback received from service users, confirmed this observation. This is instilled at staff induction and reinforced in team meetings and individual supervision. In discussion with staff they demonstrated a clear understanding of the importance in promoting dignity and respect when engaging with service users. Despite the challenging behaviours exhibited by service users, staff were observed treating service users as individuals first, following which strategies for managing the behaviours were applied. This is positive. Meals were also observed and it was deduced that service users were quite pleased the meals provided at Thornebury Nursing Home. The evening meal was nutritionally balanced, varied and specific to the service users’ needs. Most individuals commented that they meals were ‘very good’. They also commented that they were given choices and that staff were quite flexible during meal times. It was observed that service users were drinking in personalised mugs, which they personally designed, which is positive. Some of the dishes served up included Chinese, Italian, Indian and traditional English cuisine. Mealtimes were unrushed and up two service users take responsibility for preparing their meals. Some service users have an opportunity on a weekly basis to develop their culinary skills with support from the activity coordinator, which is positive. Food supplies were very good across the board. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,20) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users continue to benefit from receiving personal support in line with their needs. The management and staff work well to ensure that their physical and emotional needs are met. The support provided with medication ensures that service users health and welfare is promoted. EVIDENCE: There was good evidence from the support plans seen, to confirm that service users’ preferences are identified and recorded. More importantly most of the staff demonstrated a clear understanding of how service users are managed on an individual basis. It is true to say that the ethos in the home is one in which the service user plan is used as a working tool. There are clear arrangements in place for individual service users in relation to getting up, going to bed, having a bath, and engaging in activities. Staff were observed working closely within the agreed guidelines, allowing for flexibility in individual cases. This is important, as it is quite normal for a service user to express an alternative choice or to change their minds. Staff were observed managing this effectively. Service users were observed wearing appropriate clothing in relation to their culture and the weather, which was positive. A key worker system is in place, which provides good support to enable service users to achieve their personal goals. This is enhanced by the specialist support e.g. psychologist, district Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 16 nurse and psychiatrist, where appropriate. From the documentation seen, it was clear that service users’ health was monitored regularly and appropriate referrals made – at an early stage to reduce the risk of complications. There is a medication policy in place for the benefit of staff in the home. Service users receive support from staff that are suitably qualified to so do in that they are usually registered mental health nurses. Despite this service users are given the opportunity to have their medication independently and two had taken up this opportunity. Medication administration and accompanying records examined and found to be of a good standard. Staff had a good understanding of the desired effects of the medication used, as well as the steps required to promote the service users’ safety in the event of an emergency. The circumstances around a drug error prior to the inspection were examined and the lessons learnt from the incident explored with the manager and the deputy on the day of the inspection. It must be stated that the remedial steps taken were appropriate and minimised distress and risks to the individual concerned. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (22,23) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users and their relatives are assured that when complaints are raised – that they would be acted upon. Sound procedures are in place to promote the protection of service users living in the home. EVIDENCE: A complaints procedure is in place and available to service users, relatives, staff and external professionals. Feedback received from all service users indicated a strong awareness of their right to complain. More importantly staff demonstrated a good awareness of the need to support service users to complain should they become unhappy with any aspect of the service. There has been an improvement in the signing of all complaints, which is now done by the manager. There were three complaints since the last inspection and they thoroughly managed with the outcomes recorded. A compliments record is also maintained and there was evidence of positive comments made about the service. Good systems remain in place to safeguard service users from abuse, which included a clear and accessible protocol on abuse, and specific training in relation to safeguarding service users. From observing practice in the home, speaking with the management and staff team – it was clear that every effort is taken to protect service users from abuse. There was one potential safeguarding concern since the last inspection, which did not progress and so service users remain assured that they are in safe hands. This is reinforced by the robust recruitment practices of the organisation. During the course of the inspection, a significant number of the staff team were having safeguarding adults training on the premises. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (24,27,30) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users enjoy a generally safe environment, which has been enhanced with improvements carried out by the registered persons. A high standard of cleanliness ensures that the home remains a safe place for all. EVIDENCE: On the day of the inspection the home was clean, tidy and in good decorative order. Service users benefit from a range of facilities including: toilets, bathrooms, bedrooms, lounges for dining, relaxation and recreating, and a rear garden. The environment is homely and service users were observed enjoying various parts of it during the course of the inspection. Feedback from external professionals indicated that the home is always well maintained. Some of the improvements carried out included; replacing the furniture in the activity lounge, removal of the cobwebs as identified in the last report and repairs to the toilet seats in houses 5 and 9. Service users are now more comfortable and pleased with the improvements. There are adequate toilets and baths for the service user group. These facilities are appropriately cited throughout the home and service users were seen using them with ease. As stated earlier repairs have been carried out to the toilet Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 19 seats in houses 5 and 9, and the manager was advised to carry out routine checks as part of health and safety – on toilet seats throughout the home. The premises were clean and hygienic during the course of the inspection. The registered persons have updated policies and procedures in place to ensure that the health and safety of service users is preserved. Sound facilities remain in place for staff to clean their hands and signs were appropriately posted to ensure that a good standard hygiene is observed throughout the home. Staff spoken to showed a good understanding of their responsibility under health and safety. The home complies with the Water Supplies Regulations 1999. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (32,34,35,36) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users benefit from a staff team that is committed and adequately supported providing care to them. Staffing levels generally reflect the needs of service users including at peak times. Recruitment practices ensure that service users remain in safe hands and improvements in staffing supervision enhances the overall quality of services provided at Thornebury Nursing Home. EVIDENCE: On the day of the inspection staff were engaging with service users in a positive manner, despite the level of intervention. There was an air of calm throughout the course of the inspection and service users seemed quite reassured about the care and support they were receiving. Staff demonstrated a sound understanding of the service users’ needs throughout the course of the inspection. One service user commented; “the staff are very good here – they don’t come any better than this”. This sentiment was echoed in the written feedback received from service users. Eleven of the sixteen staff have at least an NVQ Level 2 in Care or higher and the impact of this can be measured by the fact that there have been no re-admissions to hospitals for mental treatment. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 21 Two staffing files were examined and the recruitment practices were found to be satisfactory. Two references were in place for both staff and criminal bureau reference checks were in place appropriately carried out. One of the staff members spoken to confirmed that the employers carried out all the necessary checks as required by regulation and that there was a detailed induction programme. All staff have access to a copy of the General Social Care Council’s code of conduct. There was an improvement in this standard and service users will benefit from the robustness demonstrated in the recruitment practices. A training and development plan was in place at the home and this is a strong area of the home’s operations. The training provide d is specific the service users with a mental health problem. All staff have attended their mandatory training and there was evidence that refresher training has also been made available to staff. Other training that has been provided apart from the mandatory and NVQ included; medication, mental health awareness, information technology, and infection control. There has been an improvement in the frequency of formal supervision provided to staff. There was also evidence that appraisals were carried out. Staff spoken to, felt that the manager was; supportive, approachable and encouraged good teamwork in achieving service users’ objectives. Regular staff meetings also give staff an opportunity to gain support and to make contributions towards developing the service. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (37,39,42) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Good management systems are in place to provide a quality service at Thornebury Nursing Home. This includes the systems for quality assurance. Although health and safety is generally well-promoted in the home, improvements must be made in relation to the storage of food. EVIDENCE: The manager was in the process of being registered having been the deputy previously. She is a qualified Registered Mental Nurse and is currently pursuing her Registered Managers Award. She keeps updated in areas such as the Mental Capacity Act, Safeguarding Adults training, Stress Management, and Medication Training and Audit to list a few. Staff and service users reported that she is approachable and operates an open-door policy, which suits most of the people spoken to. In discussions with her she was clear on her responsibilities and has a good understanding of the needs of the service user group. Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 23 There was good evidence that quality assurance is taken seriously by the organisation and to this end they have achieved the ‘Investors in People Award’ and the Quality Management System ‘ ISO 9011:2000, which is useful in ensuring that regular audits are carried out on the service. An internal audit was reportedly carried out, but the report was unavailable at the time of the inspection. Monthly provider visits are taking place on a regular basis. An Annual Development Plan was in place and there was evidence of some of the work that had been carried out from this plan. There are systems in place for gathering the views of service users, staff, relatives and external stakeholders. This is positive. There was evidence that key steps had been taken in the promotion of health and safety in the home, which begins with, clear policies and procedures, staff training, and the monitoring of health and safety practices in the home. Staff spoken to had a good understanding of their roles in promoting health and safety. Water temperatures were regularly monitored with clear action to be followed in the event of an abnormal reading. All health and safety records were in order. However, food storage needed to improve and this could be done, as part of the home’s internal monitoring. Thornebury Nursing Home DS0000065852.V354229.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 Adults 18-65 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 3 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 3 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 25 NO 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 YA42 Regulation 13 (4) (a) & (c) Requirement The registered persons are required to ensure that food is stored appropriately at all times. Timescale for action 08/01/08 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 Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Thornebury Nursing Home DS0000065852.V354229.R01.S.doc Version 5.2 Page 27 - 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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