Inspection on 27/07/04 for Thornham Grove

Care Home For Older PeopleThornham Grove137 Chapel Street Ibstock Leicestershire LE67 6HGUnannounced Inspection27th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Thornham Grove Address 137 Chapel Street, Ibstock, Leicestershire, LE67 6HG Email address surjit@rushcliffecare.co.uk Name of registered provider(s)/company (if applicable) Rushcliffe Care Limited Name of registered manager (if applicable) Vacant Type of registration Care Home No. of places registered (if applicable) 34 Tel No: 01530 262573 Fax No: 01530 262573Category(ies) of registration, with (number of places) Dementia - over 65 years of age (15), Learning disability over 65 years of age (4), Mental Disorder, excluding learning disability or dementia - over 65 years of age (3), Old age, not falling within any other category (34), Physical disability over 65 years of age (4), Sensory Impairment over 65 years of age (4) Registration number C010000598 Date first registered Date of latest registration certificate 16th March 2004 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 16th March 2004 YES NO 19/03/04 If Yes refer to Part CThornham GrovePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 327th July 2004 09:30 am Mrs C Burgess NA NA NA NA Ms C Stacey, Senior ManagerID Code093706Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionThornham GrovePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementThornham GrovePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Thornham Grove. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Thornham GrovePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Thornham Grove is a residential care home for thirty-four older persons of both sexes. It is a modern, purpose built home comprising of four interlinked bungalows ­ `Redlands, `Rose Villa, `Park View and `Elbow Row. The home provides care for a limited number of older persons with learning disability, mental disorder, physical disability and sensory impairment. It also offers a small number of respite placements and, in addition, has a Day Care Unit for up to twelve older persons. The home is bright and clean with a high standard of décor throughout and provides a safe and caring environment for all of the service users. One double bedroom has an en-suite facility and there are adequate toilet and assisted bathing facilities throughout the building. Each bungalow has its own sitting room/dining area and kitchen. There is also a bar where service users are able to purchase a drink in the evening. There is a secure, attractive courtyard garden in the centre of the property and well-kept gardens to the front. It is situated in the centre of Ibstock, close to all the usual amenities such as, shops, post office etc. and is easily accessible by public transport or car and there is sufficient parking for visitors. NB. Thornham Grove recently transferred ownership from Leicestershire County Council to Rushcliffe Care Ltd in March 2004.Thornham GrovePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Thornham GrovePage 6 Standards not examined during this inspection will be examined later in the inspection year. One requirement and recommendation were made at this inspection. Choice of Home (Standards 1-6) Five of the six standards examined and all were met. Thornham Grove has a comprehensive Statement of Purpose and Service Users Guide, which fulfils the Care Homes Regulations 2001 and the National Minimum Standards (NMS). The Statement of Purpose details staff experience, qualifications and training and the range of facilities, which the home provides. This clearly identifies the homes capacity to meet service users needs and is reflected in service users individual assessments and plans of care. Health and Personal Care (Standards 7-11) Three of the five standards were examined and two were met. The four service users files seen were comprehensive and inclusive and contained all of the required information. In addition, further social history information was provided, such as, `Getting To Know You to enable a `rounded and individualised care plans to be produced. Each service user has a daily care diary, which reflect the activities of daily living. Daily Life and Social Activities (Standards 12-15) One of the four standards was examined and were met. Two service users said that they were able to receive visitors at any time. Visiting times are addressed in the homes Statement of Purpose. Complaints and Protection (Standards 16-18) One of the three standards was examined and were met. Thornham Grove has a comprehensive complaints procedure, which is provided for service users at the point of admission to the home, in the Statement of Purpose and Service Users Guide. Rushcliffe Care Ltd will deal with all complaints according to company policy. Advocacy services are detailed on the reception notice board. Environment (Standards 19-26) Seven of the eight standards were examined and were met. Thornham Grove is a residential care home for thirty-four older persons of both sexes. It is a purpose built home comprising of four interlinked bungalows ­ `Redlands, `Rose Villa, `Park View and `Elbow Row. The home is bright and clean with a high standard of décor throughout and provides a secure and caring environment for all service users. One double bedroom has an en-suite facility but there are adequate toilet and assisted bathing facilities throughout the building. Each bungalow has its own sitting room/dining area and kitchen. There is also a bar where service users are able to purchase a drink in the evening. There is a safe, attractive courtyard garden in the centre of the property and has a well kept garden to the front of the property. The home is easily accessible by public transport or car and there is sufficient parking for visitors. Staffing & Management (Standards 27-38) Six of the twelve standards were examined and were met. Thornham Grove provides four staff am/pm shift and two night staff with a senior person `on call at night. In addition, the Registered Manager and/or Senior Manager are also on duty during the day. There are additional domestic staff, cooks and maintenance staff. A number of staff are concerned that staffing has been reduced by Rushcliffe Care Ltd and particularly identified `thin times in the morning when service users required help with bathing, dressing and breakfast etc. Management acknowledged that staffing had been Thornham Grove Page 7 reduced but that this was being monitored. Service Users/Relatives Comments: Service users said that they were happy at Thornham Grove; that the staff were kind and that the food was good.Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicates a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 13 OP9 The Registered Provider shall make Immediate arrangements for the recording of medicines received into the home at all times.Thornham GrovePage 8 Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements.RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard NONECONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NONEMet (Yes / No)Thornham GrovePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The Registered Person is required, in accordance with Regulation 13(2), to make suitable arrangements for the recording, 03/08/04 handling, safekeeping, safe administration and disposal of medicines received into the home.113OP9RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 OP27 The Registered Provider is recommended to revisit staffing levels, particularly regarding the early morning routine.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10. Thornham Grove Page 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NA YES YES NO NO NA YES NO YES YES YES YES NA NO NO YES YES YES 4 0 0 YES YES YES YES 35 0 27/07/04 09.30 4Thornham GrovePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Thornham GrovePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 286 To (£) 391Any charges for extrasYESHAIRDRESSING, PRIVATE CHIROPODY, SPECIAL TOILETRIES, NEWSPAPERSIf yes, please state what the extras are: 3 Key findings/Evidence Standard met? Thornham Grove has a comprehensive Statement of Purpose and Service Users Guide, which fulfils the Care Homes Regulations 2001 and the National Minimum Standards (NMS).Thornham GrovePage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Thornham Groves service users have the `old Terms and Conditions transferred from the Local Authority. All `new service users will receive a Rushcliffe Care comprehensive Service Users Guide, which includes a `Contract of Residence.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? Rushcliffe Cares management team are overseeing the updating of all service users records. Four service users files were examined on the day of inspection. They were comprehensive and contained full details of the Activities of Daily Living, Medical Histories, Risk Assessments, Nutritional Assessment, Pressure Area Risk Assessments and Fall Assessment Scoring. The list is not exhaustive. Prior to admission service users will receive a detailed assessment by a senior manager, with the involvement of the service user, service users relative and/or representative. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Information relating to visits and trial periods are addressed in the Statement of Purpose, under `Admission.Thornham GrovePage 14 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Thornham Grove does not provide intermediate accommodation. Therefore this standard does not apply.Thornham GrovePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The four service users files seen were comprehensive and inclusive and contained all of the required information. In addition, further social history information was provided, such as, `Getting To Know You to enable a `rounded and individualised care plans to be produced. Each service user has a daily care diary, which reflect the activities of daily living.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 6 03 Key findings/Evidence Standard met? The four service users files examined had detailed records of service users health requirements and had medical cards/appointments etc, in the file. General Practitioner (GP) and District Nurse visits support the provided care and detailed service user risk assessments underpin the homes commitment to maintaining service users health and wellbeing.Thornham GrovePage 16 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? Thornham Grove has a `Medicines Policy and Procedure, for the safe handling of medicines. Senior Carers, who have received medication training, administer all medicines. Medicines, including Controlled Drugs, are received, stored and disposed of appropriately. Rushcliffe Care Ltd has provided a mobile, lockable medicine trolley. However, on the day of inspection there were a few gaps on the Medication Administration Records (MAR) sheets. This was identified and a requirement made at the last inspection in March 2004. The Registered Person is required, in accordance with Regulation 13(2), to make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Thornham GrovePage 17 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Two service users said that they were able to receive visitors at any time. Visiting times are addressed in the homes Statement of Purpose.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Thornham GrovePage 18 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Thornham GrovePage 19 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 X 3 Key findings/Evidence Standard met? Thornham Grove has a comprehensive complaints procedure, which is provided for service users at the point of admission to the home, in the Statement of Purpose and Service Users Guide. Rushcliffe Care Ltd will deal with all complaints according to company policy. Advocacy services are detailed on the reception notice board. Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Thornham GrovePage 20 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 00 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Thornham GrovePage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Thornham Grove is a residential care home for thirty-four older persons of both sexes. It is a purpose built home comprising of four interlinked bungalows ­ `Redlands, `Rose Villa, `Park View and `Elbow Row. Each bungalow has its own sitting room/dining area and kitchen. There is also a bar where service users are able to purchase a drink in the evening. The home is bright and clean with a high standard of décor throughout and provides a secure and caring environment for all service users. One double bedroom has an en-suite facility but there are adequate toilet and assisted bathing facilities throughout the building. There is a secure, attractive courtyard garden in the centre of the property and has a well kept garden to the front of the property. The home is easily accessible by public transport or car and there is sufficient parking for visitors. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? The home fully complies with this standard.Thornham GrovePage 22 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Thornham Grove service users rooms have a hand washbasin and one double room has en-suite facilities. There are adequate toilets, showers and assisted bathing facilities throughout the building. Bathrooms are spacious and allow space for hoists and wheelchairs.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Thornham GrovePage 23 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 32 0 1 1 32 01 0 1 03 Key findings/Evidence Standard met? The home complies with this standard. The room sizes were not measured during this inspection and there are a number of double rooms that are currently being used as singles.Thornham GrovePage 24 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Service users rooms are individually decorated and furnished. They are personalised with furniture, photographs and ornaments. All rooms have a smoke detector and nurse call facility. Service users have a lockable facility available in their room and all bedroom doors are fitted with locks. A service users room had a bedside table that had slight damage and may require repair/replacement. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Thornham Grove has emergency lighting and all areas of the home are well lit. Rooms are fitted covered radiators and are controlled in each room by thermostatic valves. Rooms are well ventilated. Water is stored and distributed at the correct temperature, when checked on the day of inspection was less than 43 degrees Celsius. Water temperatures are checked regularly by the home.Thornham GrovePage 25 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? All areas of Thornham Grove appear to be clean and hygienic and free from offensive odours. Service users said that they believed that the home was well maintained and kept clean.StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 5 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence Thornham Grove 15 10 562 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 432.5 X X X0 35 17 Standard met? 3 Page 26 Thornham Grove provides four staff per day shift and two night staff with a senior person `on call at night. In addition, the Registered Manager and or Senior Manager are also on duty during the day. There are additional domestic staff, cooks and maintenance staff. A number of staff are concerned that staffing has been reduced by Rushcliffe Care Ltd and particularly identified `thin times in the morning when service users required help with bathing, dressing and breakfast etc. Management acknowledged that staffing had been reduced but that this was being monitored. NB. The care staff hours provided on the day of inspection was 432.5, as shown above. However the Company Manager has stated that the hours provided are 632. This will be reviewed at the Announced Inspection later in the inspection year. The Registered Provider is recommended to revisit staffing levels, particularly regarding the early morning routine.NB. Hours as illustrated in the above calculation are presented as guidance only in this report and are in accordance with the Department of Health Residential Forum Guidelines.Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 X X 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Thornham GrovePage 27 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Thornham GrovePage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? Thornham Grove has a Registered Manager at the time of inspection.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? Thornham Grove, Rushcliffe Care Ltd, complies with this standard. A `Client Survey Information review, completed yearly ­ is due in September 2004 and a menu questionnaire is undertaken to ensure service user input to meals.Thornham GrovePage 29 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? Thornham Grove, Rushcliffe Care Ltd, complies with this standard. Certificates of insurance and registration are clearly displayed within the home.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not inspected during this inspection but will be inspected later in the inspection year.Thornham GrovePage 30 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Thornham Grove, Rushcliffe Care Ltd has policies and procedures, which are comprehensive and fully comply with Commission for Social Care Inspection (CSCI) requirements and are being implemented by the management team. All service users files are kept secure in accordance with the Data Protection Act 1989.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Thornham Grove, Rushcliffe Care Ltd, has a Health and Safety Policy outlining safe working practices and has regular recorded fire drills and fire alarm tests. There are smoke detectors throughout the home. The home has emergency lighting, which is regularly checked and a file containing Control Of Substances Hazardous to Health (COSHH) risk assessments. Water temperatures are checked monthly and were within the required temperature range. The home has maintenance personnel who maintain the home and gardens.Thornham GrovePage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceRegulation Inspector Second Inspector Regulation Manager DateCarole Burgess Not Applicable Sue ShawSignature Signature SignatureThornham GrovePage 32 Public reports It should be noted that all CSCI inspection reports are public documents.Thornham GrovePage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 27th July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleThornham GrovePage 34 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 1st September 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here Thornham GrovePage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Ms Karen Watson of Thornham Grove confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Ms Karen Watson of Thornham Grove am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Thornham GrovePage 36 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!