Inspection on 18/01/06 for Thornfield Care Home

This inspection was carried out on 18th January 2006.

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

The inspector 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

Thornfield Care Home 26/09/08

Thornfield Care Home 09/08/06

Thornfield Care Home 01/02/05

Thornfield Care Home 14/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Thornfield Care Home 8 Milford Road Lymington Hampshire SO41 8DJ Lead Inspector Mrs Pat Trim Unannounced Inspection 18th January 2006 08:30 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 Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 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. Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thornfield Care Home Address 8 Milford Road Lymington Hampshire SO41 8DJ 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) 01590 676191 Mr M A Poordil Mrs S Poordil Mrs S Poordil Care Home 17 Category(ies) of Dementia (17), Dementia - over 65 years of age registration, with number (17), Mental disorder, excluding learning of places disability or dementia (17), Mental Disorder, excluding learning disability or dementia - over 65 years of age (17), Old age, not falling within any other category (17), Physical disability (2), Physical disability over 65 years of age (2) Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users in the categories MD, DE and PD must be at least 55 years of age A maximum of 2 service users in the PD and PD(E) categories may be accommodated at any one time 12th July 2005 Date of last inspection Brief Description of the Service: Thornfields provides care and accommodation for 17 service users who are older persons or older persons with dementia. The service is registered to accommodate service users over the age of 55 years who have dementia or mental health problems and 2 service users over the age of 55 years who have a physical disability. The home is privately owned by Mr. and Mrs. Poordil. Mrs. Poordil is the registered manager, although the day to day running of the home is shared between them. The building is a large family home that has been extended to provide bedrooms on 2 floors. There are 9 single and 4 shared rooms. 7 of these have en suite facilities. Communal space comprises a large lounge diner and conservatory. There is a stair lift to enable service users access to both floors. The home has car parking space at the front of the property and a large enclosed garden and patio area to the rear. Thornfields is situated on a busy main road, close to local shops, amenities and public transport. Lymington is a short distance by car. Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory inspection for 2005/2006 and was unannounced. The focus of the inspection was to assess key standards not covered on the previous inspection and to review the requirement made in the last report. For an overview of how the home is meeting the key standards, both reports should be read. This inspection was completed in four hours by one inspector. Information was gathered by speaking with five residents, two staff and Mr. and Mrs. Poordil. Time was spent looking at a number of records and information was also obtained from the pre inspection questionnaire, completed by the provider before the previous inspection. What the service does well: What has improved since the last inspection? What they could do better: The current systems in place for auditing the quality of the service provide some feedback from residents and their families. These systems need to be Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 6 developed so that the providers can be confident all residents are able to give feedback on the service they receive. The current employment procedure provides sufficient information to ensure new staff are fit to work in the home. However, when staff are recruited from another country, the checks carried out must include a Protection of Vulnerable Adults (POVA) and a Criminal Records Bureau (CRB) disclosure completed in this country, prior to the person starting work at the home. 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. Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 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 Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 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): 3. Standard 6 does not apply The use of a comprehensive assessment tool, completed prior to admission, means that residents may be confident their needs can be met. EVIDENCE: The files for three residents, recently admitted, were assessed. Two contained assessments completed prior to admission. These identified abilities as well as needs and highlighted any areas of risk. For example, in respect of medication the assessment identified whether the resident was able to self medicate, whether they required prompting or whether they required someone to administer it. A more comprehensive assessment was completed on admission to review and add to the information already obtained. Mrs. Poordil said that the third resident had been admitted as an emergency during the Christmas period. Information about the resident’s needs had been given verbally to the provider and an assessment of need completed on admission. This complies with the requirement that an assessment of need must be completed within five days of admission in respect of an emergency Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 9 placement. The home’s statement of purpose gives information about the home’s emergency placement procedure. Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 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): These standards were assessed on the last inspection. EVIDENCE: Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 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 the following standard(s): These standards were assessed on the last inspection. EVIDENCE: Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 12 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 and 18. The robust complaints procedure enable residents to be confident their complaints will be listened to and addressed. Staff training, together with the procedures in place, ensure residents are protected against the risk of abuse. EVIDENCE: The home had a complaints procedure that identified who would investigate complaints and the timescales for responses. A copy of the procedure was included in the service users’ guide. Every resident was given a copy of this and a copy was kept on the notice board. A written record was kept of any complaints made to the providers, together with what action was taken and what the outcome was. Residents who were spoken with during the inspection said they felt quite comfortable about making complaints to the provider and were satisfied their concerns would be addressed. The home had a policy and procedure, including a whistle blowing policy, for the protection of vulnerable adults. Staff were expected to familiarise themselves with these as part of their induction process. The home had a copy of Hampshire’s adult protection procedure, which staff were also expected to read. Four of the eight staff had attended training in adult protection. The provider said that the need to continue training in adult protection had been identified Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 13 as a learning need. The home had acquired a training video and it was hoped this would be a useful tool to help staff develop their skills. The provider said he felt it would be used as part of staff supervision to enable them to discuss issues and raise their awareness. Two staff were asked about adult protection issues. Both were able to identify what their responsibilities were and how the procedure worked. Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 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 the following standard(s): These standards were assessed on the last inspection. EVIDENCE: Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 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 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 and 29 The providers enable staff to attend appropriate training so that residents can be confident staff have the skills they need to meet their needs. A more robust employment procedure must be followed if residents are to be protected. EVIDENCE: The providers enabled staff to undertake ongoing training and two staff have National Vocational Qualification 2 (NVQ 2). One member of staff has achieved NVQ 3 and one has an equivalent qualification from overseas. One staff is shortly to start her NVQ 2. This means the home has 50 of staff who have NVQ 2 or above and the standard is met. At the previous inspection a requirement was made that all new staff must have a Protection of Vulnerable Adults (POVA) check and Criminal Records Bureau check (CRB) completed prior to their employment. The checks had been completed for a member of staff who was going through the employment procedure at the time of the last inspection and copies were on file. Only one member of staff had been employed since the requirement was made. She had been employed from overseas through an agency. A CRB had been completed in her country of origin and a translated copy was kept on file. However, no POVA or CRB had been obtained following her arrival in this country. The providers were informed that these checks must be completed following the care staff’s arrival in this country and prior to them beginning Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 16 their employment in the home. They were advised to refer to the POVA guidance and a requirement was made that these checks must be completed. If it is essential for a member of staff to begin their employment prior to the POVA and CRB being returned, a POVA first check must be completed and the provider must contact the Commission for Social Care Inspection to confirm all relevant checks have been completed. Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Residents benefit from a service that is run in their best interests by a wellqualified registered manager. The policy of the home in respect of managing residents’ money ensures they are protected from the risk of financial abuse. Arrangements for the regular servicing of equipment and staff training protect the health, safety and welfare of residents. EVIDENCE: Mrs. Poordil has completed the registered managers’ award and has a nursing qualification. She and her husband have been running Thornfields for five years and both continue to develop their skills by attending relevant training. Staff and residents said they felt well supported by the providers and that they were always in the home and happy to discuss any issues. Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 18 Mr. and Mrs. Poordil said they were developing ways of getting feedback from residents about the service they receive. They ensured residents could express their views by making sure they were easily accessible. They also sent out satisfaction questionnaires. Copies of the last one, completed in November 2005 had only positive comments from residents about the service they receive. Families are also asked to contribute. Residents confirmed the providers asked them about the quality of care. Mr. Poordil said that he was currently completing the registered manager’s award and was reviewing quality audit procedures as part of this. He was looking at how a more user-friendly format for questionnaires could be used to enable residents to give feedback. Mr. Poordil said that a monthly audit of the service was completed each month. This enabled him to identify any areas of concern and to take action to resolve issues. The providers said that it was the policy of the home not to hold any money on behalf of residents. Those who were able to paid directly for services such as hairdressing and chiropody. The providers paid any bills for residents who could no longer manage their money and invoiced the family for any expenses incurred. The providers said that staff had an annual appraisal to identify training needs and from this a training programme was drawn up for the year. Core training such as moving and handling, first aid and food hygiene was arranged to meet these identified needs. For example, Mrs. Poordil said she had identified that some staff needed refresher training in moving and handling and this was being arranged. The providers had contracts with a number of companies to provide services and maintenance to the home. A random selection of these contracts were seen during the course of the inspection and a list of them were sent to the Commission for Social Care Inspection by the provider as part of the information received through the year. Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 19 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 20 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 29 Regulation 19 Requirement You are required to obtain a POVA first check for all staff prior to their employment. This includes any staff coming from overseas to work in the home. Timescale for action 18/01/06 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 Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Thornfield Care Home DS0000011794.V277598.R01.S.doc Version 5.1 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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