Inspection on 03/05/05 for Thornham Grove

This inspection was carried out on 3rd May 2005.

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

Thornham Grove 04/07/06

Thornham Grove 01/08/05

Thornham Grove 27/07/04

Thornham Grove 10/03/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

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

CARE HOMES FOR OLDER PEOPLE Thornham Grove 137 Chapel Street Ibstock Leicestershire LE67 6HG Lead Inspector Mrs Carole Burgess Unannounced 3 May 2005 09:30 rd The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Thornham Grove Address 137 Chapel Street Ibstock Leicestershire LE67 6HG 01530 262573 01530 262573 surjit@rushcliffecare.co.uk Rushcliffe Care Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Patricia Lynn Austen CRH 34 Category(ies) of Dementia - over 65 years of age (15), Learning registration, with number disability over 65 years of age (4), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (3), Old age, not falling within any other category (34), Physcial disability over 65 years of age (4), Sensory Impairment over 65 years of age (4) Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person falling within category DE(E) may be admitted to the home when 15 persons who fall within category DE(E) are already accommodated within the home. 2. No person falling within category MD(E) may be admitted to the home when 3 persons who fall within category MD(E) are already accommodated within the home. 3. No person falling within category LD(E) may be admitted to the home when 4 persons who fall within category LD(E) are already accommodated within the home. 5. No person falling within category SI(E) may be admitted to the home when 4 persons who fall within category SI(E) are already accommodated within the home. 6. Service useres between the age of 55-65 years who fall within the above categories and were resident in the care home at the date of registration may continue to reside there. Date of last inspection 6th September 2004 Brief Description of the Service: 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 zones – ‘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 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 zone has its own sitting room/dining area and kitchen. There is also a bar where service users are able to obtain a drink in the evening. There is a safe, 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. There is sufficient parking for visitors. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day. An opportunity was taken to look around the home, view records, policies and care plans and to talk to staff and residents. The primary method of inspection used was ‘case tracking’ which involved selecting four residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Many of the residents were seen during the inspection and six of the residents and four relatives spoken to gave the inspector their impressions of the home. What the service does well: What has improved since the last inspection? The home now has a Registered Manager to ensure that there is good leadership and stability in the home. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 6 The open and positive attitude of the staff is in contrast to the situation twelve months ago, when the home had transferred ownership from Leicestershire County Council to Rushcliffe Care Limited in March 2004 and staff were feeling anxious about the changes which had occurred. This noticeable change ensures that staff work well together to provide the best care for the residents. Medication management and administration has improved, particularly in relation to recording, to ensure that residents always receive their prescribed medication. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5. The admission process is well managed and residents are given clear and detailed information regarding the service; thereby ensuring that the residents’ health and welfare needs are being met. EVIDENCE: There is a comprehensive Statement of Purpose & Service Users’ Guide and a signed copy of the Terms and Conditions in residents’ files. The pre-assessment process is detailed and robust and reflective of the health and welfare needs of the residents. Two relatives said that they were able to visit the home prior to their relative taking up residence and two prospective residents came to view the home during the inspection. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11. Residents are looked after well in respect of their health and personal care needs. EVIDENCE: Care plans have been revised from those used by the previous provider. They are now detailed and reflect residents’ specific and individual needs. Contact with other healthcare professional is well documented. The quality of record keeping is reflective of the high standard of care observed during the inspection and ensures that the needs of the residents are met. However, further attention could be given to involve residents and/or their relatives in the care planning process. A number of residents’ files did not show resident/relative/representative involvement. Nevertheless, it was also evident that the Registered Manager is addressing this issue. Relatives said that they were consulted and were able to voice general comments and/or concerns at any time. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 10 Medication administration has greatly improved since the previous inspection and is now managed effectively within the home’s robust medication policy and procedural guidelines to ensure the safe and timely delivery of residents’ prescribed medicines. Observation during the inspection showed that staff have a good awareness of how to protect residents privacy and dignity. They were seen to be kind and patient and treated the residents in a respectful, friendly and supportive way. Residents and their relatives said that staff are respectful and very caring. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15. Residents experience a stimulating and varied life at the home with visitors encouraged and a variety of activities made available. Meals are well presented and nutritious and staff are caring and supportive of residents and their relatives. EVIDENCE: Visitors came and went throughout the day. Residents were having their hair ‘done’ by the hairdresser, who visits the home every Tuesday, and took part in activities, such as bingo, which are provided daily in the lounge as part of the Day Care programme, and is flexible to meet the residents’ needs and preferences. Residents spoken to said that staff are respectful and very caring and both residents and relatives said that the staff were excellent and provided a very high standard of care. Menus are balanced and appealing, and are flexible enough to accommodate individual preferences and healthcare needs. They are freshly prepared and are of a good standard and the residents said that they enjoyed their meals and are able to choose when and where they take them. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 12 Two relatives gave special praise for the staff who had supported them through a difficult time and bereavement; providing care for their relative and themselves, both emotionally and practically, and by providing meals to enable them to remain by their loved one’s bed side. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 & 18. Arrangements for receiving and responding to complaints are generally sound, resulting in satisfactory protection of residents’ rights. EVIDENCE: Residents and staff comments demonstrate that people feel at ease discussing any concerns with the Registered Manager and the staff. The CSCI has not received any complaints about the home and the home’s complaints process reflects the government’s adult protection guidelines, set out in the No Secrets’ publication. Complaints and concerns made to the home are dealt with correctly. Two recent concerns had been dealt with. The Inspector felt that senior management may have dealt with one of the concerns inappropriately. This is currently being discussed between the CSCI and the Providers. Residents and their relatives, spoken with during the inspection, said that they had no concerns about the home and that they had every confidence in the new manager and the care staff. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 & 26. A comfortable, homely and safe standard of accommodation is provided for the residents. EVIDENCE: The home is safe and well maintained with many adaptations to suit residents’ specific needs. It is decorated and furnished to a high standard that creates a comfortable and homely environment, and there is a system of maintenance and refurbishment. There is safe garden area and the home is set in pleasant surrounding with grass, shrubs and seating areas. Residents’ rooms are clean and well decorated, and residents are able to bring items of their own furniture and possessions with them to personalise their rooms. There are sufficient toilet, bathing and assisted bathing facilities. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 15 Hot water temperatures are checked to ensure they comply with Health and Safety legislation and were satisfactory when checked during the inspection. All areas of the home were clean and maintain to a good standard. Residents and their relatives said that the home always felt warm and comfortable. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 30. Staff at the home are well trained and supported, and employed in sufficient numbers to meet the residents needs. EVIDENCE: Staffing levels, at the point of inspection were satisfactory and in line with the Department of Health Residential Forum Guidelines and were sufficient to meet the residents’ needs. Staff also said that they felt that there are sufficient staff on duty. The Senior Manager/Registered Manager maintains overall responsibility for the home. Relatives said that they felt staff were capable and caring, and that there were sufficient staff on duty to meet the needs of the residents. Training for staff is well planned and supports staff in providing for the varied needs of the residents. A calendar in the office gives a clear indication of staff training for the year. Thirteen of the care staff hold National Vocational Qualification (NVQ) in Care, Level 2 or above. Extensive ‘in house’ training supports staff in meeting the residents’ health and welfare needs. The recruitment process was not inspected during this inspection but will be checked during the next unannounced inspection later in the inspection year. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 37 & 38. The newly appointed Registered Manager, with effective supervision of staff, manages the home efficiently to protect the rights and needs of the residents. EVIDENCE: The home has a newly appointed Registered Manager with ten years of experience in care. There is an ethos of openness in the home; staff are friendly and helpful towards the residents, their relatives and each other. Staff support the residents to make decisions in their everyday life, which promote independence, such as a choice of food and what they wish to wear and do. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 18 Residents’ personal allowances are kept safe and appropriately managed where this is required. The Registered Manager undertakes yearly staff appraisals and is in the process of implementing clinical supervision (a regular review of staff performance and training needs) to ensure that staff maintain the standards of care expected throughout Rushcliffe Care Limited. Health and Safety Policy and Procedures, such as regular recorded fire drills and fire alarm tests are completed, to ensure the health and safety of the residents and staff. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 4 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x 3 3 3 3 Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 20 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 Regulation NONE Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 7 (6) 16 (3) Good Practice Recommendations The Registered Person is recommended to ensure that residents care plans are drawn up with the involvement of the residents or their representative The Registered Person is recommended to ensure that a detailed account of a complaint and outcomes is recorded in the residents file and/or the complaints file and that vulnerable adults policies and procedures are followed at all times. Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 Page 21 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park Enderby Leics LE19 1SX 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 Thornham Grove C51 S58944 Thornham Grove V218364 030505.doc Version 1.30 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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