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Inspection on 04/07/06 for Thornham Grove

Also see our care home review for Thornham Grove for more information

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Thornham Grove, Rushcliffe Care Limited provides a high standard of care for the residents. The home is well maintained and provides a good standard of accommodation. The atmosphere is homely and welcoming and staff are caring and supportive to residents and their relatives and each other. Comments from residents during the inspection were very positive and demonstrated that they were very satisfied with the standard of care provided. Care plans are detailed to ensure that each resident`s individual and specific needs are met. Residents are provided with a varied range of activities and are able to join in with those provided for people who use the Day Care facility. Meals are freshly prepared by the catering staff and are nutritious and well presented. The home`s Registered Manager, Trainee Care Manager, Senior Care Team Leaders and staff work well together to ensure that staff are well trained and enthusiastic about the care they provide for the residents and are able to meet the residents` health, welfare and social care needs. Residents spoken with were very satisfied with all aspects of care, cleanliness and food provided by in the home.

What has improved since the last inspection?

Thornham Grove continues to provide a high standard of care for the residents. Since the previous inspection in August 2005: The residents or their representative has now signed most of the care plans. The home is implementing a mouth care protocol to identify potential problems such as ill-fitting dentures or the need for dental care. Rushcliffe Care Limited now has their own team of gardeners and the gardens at Thornham Grove are being tidied up and made safe with additional fencing. Some residents` rooms have been redecorated, as have the lounges, with new flooring and carpeting in the large lounge area. There are some new chairs in day care area. The staff room has been relocated and the `old` staff room refurbished to provide a quiet room for staff or for residents and relatives.

What the care home could do better:

There were no requirements or recommendations following this inspection. The recommendations made following the previous inspection to ensure that care plans were signed by the residents or their representative, to demonstrate agreement; and to trim back foliage from paths so that they were safe for wheelchair uses and ambulant residents, have been addressed.

CARE HOMES FOR OLDER PEOPLE Thornham Grove 137 Chapel Street Ibstock Leicestershire LE67 6HG Lead Inspector Mrs C A Burgess Unannounced Inspection 4th July 2006 09:30 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 Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornham Grove Address 137 Chapel Street Ibstock Leicestershire LE67 6HG 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) 01530 262573 01530 262573 Rushcliffe Care Limited Mrs Patricia Lynn Austen Care Home 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), Physical disability over 65 years of age (4), Sensory Impairment over 65 years of age (4) Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Categories DE(E) 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. Service User Categories MD(E) 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. Service User Categories LD(E) 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. Service User Categories PD(E) No person falling within category PD(E) may be admitted to the home when 4 persons who fall within category PD(E) are already accommodated within the home. Service User Categories SI(E) 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. Service users Service users 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. 1st August 2005. 2. 3. 4. 5. 6. Date of last inspection 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 residents. 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 Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 5 room/dining area and kitchen. There is also a bar where residents 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. The Statement of Purpose, Service Users’ Guide & Inpection Report are available on request. The Statement of Purpose and Service Users’ Guide are provided for all new residents. At the time of the site visit the Trainee Care Manager stated that weekly fees were: £319 - £430. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This site visit 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 and relatives. The primary method of inspection used was ‘case tracking’ which involved selecting three 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 a relative spoken with gave the Inspector their impressions of the home. What the service does well: Thornham Grove, Rushcliffe Care Limited provides a high standard of care for the residents. The home is well maintained and provides a good standard of accommodation. The atmosphere is homely and welcoming and staff are caring and supportive to residents and their relatives and each other. Comments from residents during the inspection were very positive and demonstrated that they were very satisfied with the standard of care provided. Care plans are detailed to ensure that each resident’s individual and specific needs are met. Residents are provided with a varied range of activities and are able to join in with those provided for people who use the Day Care facility. Meals are freshly prepared by the catering staff and are nutritious and well presented. The home’s Registered Manager, Trainee Care Manager, Senior Care Team Leaders and staff work well together to ensure that staff are well trained and enthusiastic about the care they provide for the residents and are able to meet the residents’ health, welfare and social care needs. Residents spoken with were very satisfied with all aspects of care, cleanliness and food provided by in the home. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 8 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 Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 9 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 & 6. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The admission process is well managed and residents receive a comprehensive assessment, thereby ensuring that their health and welfare needs are being met. EVIDENCE: The pre-assessment process, completed by either the Trainee Care Manager, with the support of a Registered Manager, is detailed and robust and reflective of the health, welfare and social needs of the residents, including those people receiving respite care. The home does not provide intermediate care. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are well looked after in respect of their health and personal care. EVIDENCE: Care plans were detailed and reflect residents’ specific and individual needs. Contact with other healthcare professionals is well documented in a separate file. The quality of record keeping is of a high standard and residents and/or their relatives are encouraged to participate and agree to their plan of care, which ensures that the needs of the residents are fully met. Medication administration is managed effectively within the home’s robust medication policy and procedural guidelines to ensure the safe and timely delivery of residents’ prescribed medicines. The room housing the medication fridge was very hot on the day of inspection. The fridge temperature was 9 degrees Celsius. Usually, there is a fan in this room, as it tends to become hot, but all the fans in the home were being used for the residents, as it was an Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 11 exceptionally hot day. This should be closely monitored to ensure that medication is stored at the correct temperature at all times. 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 spoken with were very positive about the care they received and said that staff are respectful and very caring at all times. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff work very hard to ensure that residents experience a safe, homely life style. EVIDENCE: Visitors came and went throughout the day and the interaction between the visitors and staff was positive, friendly and welcoming. Residents are able to take part in activities, such as sing-a-longs and bingo, which are provided daily in the lounge as part of the Day Care programme. The hairdresser visits the home every Tuesday to enable residents to have a haircut, a shampoo and set or a perm. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 13 There are celebrations throughout the year at Christmas, Valentines Day, and Easter etc; there will also be a summer fete. There is a regular church service. This enables residents and their relatives to enjoy seasonal and community activities but individual likes, dislike and preferences were recorded and respected. 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 DS0000058944.V302280.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints are sound resulting in satisfactory protection of residents’ rights. EVIDENCE: The home’s complaints process reflects the government’s adult protection guidelines, set out in the local Multi Agency Policy & Procedure For The Protection of Vulnerable Adults from Abuse, No Secrets’ publication, 2004. Staff are aware of these procedures and receive relevant training. Complaints and concerns made to the home are dealt with appropriately. Neither the home nor the CSCI have received any complaints since the last inspection in August 2005. There are regular, minuted staff and residents/relatives meetings to ensure good communication is maintained at all levels. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A comfortable, clean 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. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 16 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. Although rooms are redecorated when they become vacant and bed linen is provided a relative said that she had been able to decorate a room and provide personalised bed linen for her mother who was looking forward to moving to the home in the near future. All areas of the home were clean and maintained to a good standard. Residents said that the home was always very clean and well maintained. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at the home are sufficient in 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. The Registered, Senior Manager maintains overall responsibility for the home. The Trainee Care Manager is supernumerary for three days per week and has the support of the Senior Manager in preparing for her role as proposed Registered Manager for the home. There are four care staff on duty throughout the day and two on duty during the night, with additional cover in the mornings and evenings, during the busy periods. There are also cooks, domestic and maintenance staff. The Trainee Care Manager, staff and residents spoken with all said that there were sufficient staff to meet the residents’ needs. Training for staff is well planned and supports staff in providing for the varied needs of the residents. New staff are provided with a comprehensive induction package. A fairly new member of staff confirmed that she had undertaken a Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 18 full induction, with additional ‘in house’ training and had been well supported by management to commence her National Vocational Qualification (NVQ) Level 2 in Care. She was very complimentary about the training and support she had received since joining Rushcliffe Care Limited, and said that it had enabled her to provide informed care for the residents. NB. Rushcliffe Care Limited, Epinal Way Care Centre undertakes the recruitment process centrally. This has been inspected during this inspection year and was found to be satisfactory. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Senior, Registered Manager and Trainee Care Manager are knowledgeable, experienced and professional, and effectively supervise staff and manage the home to protect the rights and needs of the residents. EVIDENCE: Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 20 The home has a Registered Manager with more than ten years of experience in care. The Trainee Care Manager (supported by the current Registered Manager) facilitated the site visit in an open, friendly and professional manner. She has many years of experience in care and has worked for Rushcliffe Care Limited for three years, and holds an NVQ Level 2 & 3 in Care. She is currently undertaking NVQ Level 4 in Care, progressing towards the Registered Managers Award and intends to apply for registration with the CSCI. She appears very knowledgably and caring in regard to the residents and their relatives and has an open style of management, which will ensure good working relationships with staff and quality care for residents, and support for their families. 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 promotes independence. Residents’ personal allowances are kept safe and are appropriately managed. The Registered Manager undertakes yearly staff appraisals and 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. Hot water temperatures are checked to ensure they comply with Health and Safety legislation and were satisfactory when checked during the inspection. Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 4 Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation 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. Refer to Standard Good Practice Recommendations Thornham Grove DS0000058944.V302280.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester 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 DS0000058944.V302280.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!