Inspection on 19/09/07 for Thornhill House

This inspection was carried out on 19th September 2007.

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.

Other inspections for this house

Thornhill House 22/12/09

Thornhill House 24/01/07

Thornhill House 10/10/06

Thornhill House 07/12/05

Thornhill House 13/06/05

Thornhill House 08/12/04

Thornhill House 09/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Thornhill House Church Lane Great Longstone Derbyshire DE45 1TB Lead Inspector Sue Richards Key Unannounced Inspection 19th September 2007 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 Thornhill House DS0000002093.V341576.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. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornhill House Address Church Lane Great Longstone Derbyshire DE45 1TB 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) 01629 640034 John Thornhill Memorial Trust Catherine Elizabeth Headington Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration to include the accommodation of two named service users (as specified on the notice of proposal) into Thornhill House under the category DE,E not transferable to any other service users, other than those as named. The maximum number of persons to be accommodated within Thornhill House is 17 24th January 2007 2. Date of last inspection Brief Description of the Service: Thornhill House is operated by a registered charitable trust whose patron is the Duchess of Devonshire. The home provides nursing and personal care and support for up to seventeen older persons. It is purpose built single storey accommodation located in the village of Great Longstone, approximately three miles north east of the market town of Bakewell. The home provides all single room accommodation with an en suite facility to each. There is a choice of lounge and dining facilities and suitable bathing and toilet facilities. There is a central kitchen and separate laundry facility and a range of equipment both environmental and individual to assist those persons with physical disabilities, including an emergency call system throughout. The gardens are very well maintained and provide level access for service users, together with seating. Car parking spaces are also provided. The Registered Manager has internal general management and there is a team of nursing, care and hotel services staff, together with a number of volunteers from the local village and surrounding area. External support is also provided via the charity’s board of trustees. There are excellent arrangements to enable residents to engage in activities of their choice, which are planned by the activities co-ordinator employed. Close links are also well established with the local community and there is a meals’ on wheels service, which also operates from the home via employed volunteers. A copy of the most recent inspection report for this service is available on request from the office at the home. The current range of charges per week is from £527.00 (personal care only) to £662.00 (higher dependency nursing). The actual fee charged is dependant on people’s assessed needs and are inclusive, for those eligible, any agreed funding assistance from either the local authority for personal care or funded nursing care as may be determined via the local primary care trust. Day care may also be provided at a cost of £25 per day in accordance with availability. There are additional charges for hairdressing and private chiropody. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 5 Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. For the purposes of this inspection we have taken into account the information we hold about this service. This includes our previous key inspection report of 06 February 2007 and information provided in our annual quality assurance questionnaire completed by the home. We received six out of ten survey returns from people who use the service and also the same from staff. At this inspection there were seventeen people accommodated at the home who receive nursing care. We used case tracking as part of our methodology. This involved the random sampling of three people, whose care and service provision was more closely examined. We spoke with people about the care and services they receive and looked at their written care plans and associated health/care records and also inspected their private and communal accommodation. We also spoke with staff and management about the arrangements for their recruitment, induction, training, deployment and supervision. Examined related records and observed some of staffs’ interactions and approaches with others. We spoke with the registered manager about her role and responsibilities and about the management and monitoring arrangements for the home What the service does well: People live in a home, which is clean, safe and comfortable and is maintained, furnished and equipped to a high standard. People are well informed about the home and its services and their inclusion is effectively promoted throughout their admission and assessment process. People’s health and personal care needs are well met in accordance with key principles and practises, which successfully promote their individual dignity and rights. People’s wishes are well respected and they are provided with the necessary support to maximise their independence and choice with regard to their daily living arrangements. People are provided with good food in accordance with their preferences and assessed nutritional requirements. People’s views are taken seriously and acted upon and they are protected from abuse. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 7 There are effective arrangements for staff recruitment, induction, training and deployment. The home is very well managed and run in people’s best interests. 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. The summary of this inspection report can be made available in other formats on request. Thornhill House DS0000002093.V341576.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 Thornhill House DS0000002093.V341576.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 3 & 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are well informed about the home and its services and their inclusion is effectively promoted throughout the assessment process. EVIDENCE: At our previous inspection of this service we judged that people’s needs are clearly determined and well met. In our annual quality assurance questionnaire completed by the home they said that they always encourage people to visit the home before their admission. That people’s needs are effectively assessed with them and there is good liaison with outside health and social care professionals and representatives. They say they keep comprehensive records in respect of the Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 10 above and that individual testimonies and their two-page waiting list evidence this. They say that over the last twelve months they have improved their record keeping in respect of people’s admissions to the home, including information given to people about the home. They would like to provide day care for more people, although feel space be a limiting factor and are currently looking at the feasibility of this. At this inspection we looked at how key information about the home and its services is provided for people and also as to how people’s needs are assessed and determined. This included discussions with people, examination of the home’s service guide/brochure and inspection of recorded needs assessment information for those people case tracked. We also asked some people by way of a written survey if they received enough information about the home before moving in there and some staff by the same method if they are given enough information about the needs of people they support or care for. People said they are provided with sufficient information about the home and that they are always properly notified of any changes. They said that the home always discuss and agree their needs with them. Staff said that they are always provided with up to date information about the needs of the people they support and care for. The service guide provides clear and detailed information about fees charged and what they cover. People’s written needs assessment information is well recorded in accordance with recognised guidance and is inclusive of their choices and preferences as agreed with them. There was no one accommodated for the purposes of rehabilitation at this inspection, although the home has successfully supported people in this capacity in the past. All people accommodated are of white British background and of either practising or non-practising Christian based religion. There is a significant waiting list for admissions, which are from the local area. Key information about the home can be provided in large print for those people with sight difficulties, although there is no detail about its possible availability in any other formats, which may assist people, such as audiocassette. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 11 Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7, 8, 9, 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are well met in accordance with key principles and practises, which successfully promote their individual dignity and rights. EVIDENCE: At our last key inspection of this service we judged that people’s health, personal and social care-needs are well met and they are treated with the utmost dignity and respect In our annual quality assurance questionnaire completed by the home they say that people’s care plans are drawn up in accordance with people’s risk assessed needs. That people’s health care needs are well accounted for and that there is good liaison with outside health and social care professionals. They say that their staff team is well trained and that registered nurses are Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 13 supported to undertake appropriate training in respect of extended clinical role/responsibilities and that the home promotes good evidence based clinical practise. They also say that people are treated with the utmost of respect and that the promotion of people’s dignity and privacy is always considered to be a high priority. They also say that they provide good ‘end of life care’ in accordance with recognised practise. They say that happy, well-nourished residents, nil pressure ulcer incidence and low hospital admission rate are all indicators of the good care they provide. At this inspection we spoke with people about the arrangements for their care and support, including access to outside health care professionals concerned with their care and also staff’s approaches with them, which were also observed during the course of the inspection. We also examined people’s written care plans and associated health care records, including medicines records. We asked some people by way of our written survey if they receive the care and support they need and if staff listen and act on what they say. We also asked them if they receive the medical support they need. All people expressed high levels of satisfaction regarding the quality of care they received, the arrangements for the health and medical care and also staff’s approaches towards them. All said they are treated with the utmost dignity and respect at all times and that staff always listen and act on what they say. Peoples’ written care plans are well recorded in accordance with their riskassessed needs. They reflect consultation with people and clear consideration of their individual mental capacity in respect of making informed choices. They are reflective of evidence based clinical practise and have regularly recorded reviews. Inputs from outside health care professionals are well accounted for and again in accordance with people’s needs and stated wishes. The arrangements for the management and administration of people’s medicines were also examined, including where people wish to retain and manage their own medicines. One person who was recently admitted expressed the wish to manage some of their own medicines, the manager advised that this was to be risk assessed in accordance with the home’s stated policy guidance, which is satisfactory. Medicines management is in accordance with recognised practise and guidance. Although there was one very recent recording error made by two staff members in respect of a controlled medicine. However, this was an isolated incident and clearly not common practise, it did not compromise the audit trail for that medicine and established management monitoring systems in place indicate that the monthly auditing of medicines systems, including Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 14 recording would identify this. Immediately following our inspection the manager has provided written notification of the action they have taken in respect of this error, which is completely satisfactory. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12,13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People’s wishes are well respected and they are provided with the necessary support to maximise their independence and choice with regard to their daily living arrangements. People are provided with good quality food in accordance with their preferences and assessed nutritional requirements. EVIDENCE: At our last key inspection of this service we judged that peoples’ rights to live meaningful lives in accordance with their known lifestyle preferences, choices and given capacities are well promoted as is the importance of good nutrition for older persons. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 16 In our annual quality assurance questionnaire completed by the home they say that they support people to engage in a variety of activities, which accord with their lifestyle preferences and abilities, including their rights to practise their religious beliefs. They say that visiting is open and that there are excellent links with the local community who are actively involved in supporting people at the home and who the service also provides support for by way of a meals on wheels service. They also hold regular meetings with people living at the home. They say that people’s rights to autonomy and choice is well promoted and always considered and that they provide a high standard of nutritious food for people, which is locally sourced. They say they have improved by increasing activity co-ordinator hours, by recruiting an additional co-ordinator to work alongside the existing person, who is a quality occupational therapist. They say they have also reviewed their menus to account for the changes in peoples’ needs resulting from some their increasing frailty. They would like to instigate relatives meetings and plan for further staff training with regard to dementia care and nutrition. At this inspection we spoke with about their daily living arrangements including for their leisure, social and religious activities and maintaining their personal and social relationships/contacts. We also looked at how information is provided for people about these. We asked some people by way of our written survey if there are activities arranged by the home, which they can take part in and if they like the meals at the home. People said that a range of activities is arranged by the home, which they can join if they wish and that they are consulted about these. People said they are treated as individuals and that they have good relationships with staff. Information about activities and community contacts are displayed in the home on the ‘Activities/Daily Diary’ notice board and also by way of leaflet information. Examples of regular activities include outings into the local and extended community for shopping, library visits, lunches and senior citizens club. These are inclusive to all regardless of their disability and in accordance with their risk-assessed needs. In house activities include gentle exercise games, cards, bingo, quizzes, reading and arts and crafts. There are photographs of people engaging in various celebrations and activities and plaudits on display. Residents at the home who wish and are able have always been involved in the making of a well dressing on an annual basis, which is a local tradition. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 17 On the day of our inspection one person accommodated was celebrating their birthday with residents, friends and staff. A local church minister provides a regular service for people and was also present in the home. Plans are also in hand for a Festival of Light to be held at the home in December where existing and old friends of the home are to be invited in remembrance of their loved ones. A review of activities arrangements is also currently underway with the aim of ensuring these are developed further and tailored to people’s preferences and capacities. The home has a very welcoming, lively and friendly atmosphere and has established links within the local community, which includes regular and welcomed support from local volunteers. A variety of information about community facilities is provided for people, including access to advocacy services and carer associations. Information is recorded in people’s care records in respect of their daily living arrangements and individual capacity and choices, including their financial affairs. Food is provided to a good standard with local produce and fresh ingredients used. Great care is taken in the setting, serving and presentation of meals and also in assistance for service users. People said they like the meals provided, which are felt to be good quality. There were no service users with special religious or cultural dietary needs. Special diets are catered for and the nutritional status of each service user is assessed and monitored with records maintained in respect of these. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Peoples’ views is taken seriously and acted upon, they are protected from abuse. EVIDENCE: At our last key inspection of this service we judged that the systems and arrangements in place regarding of the protection of service users from abuse and their rights to complain are satisfactory. In our annual quality assurance questionnaire completed by the home, they say that they maintain a clear and robust complaints policy that is readily accessible and there is also a complaints book in the general office. That their policy and procedural guidance in respect of safeguarding vulnerable adults is also robust and that training for staff regarding this is mandatory and that all staff are conversant with their responsibilities. The manager is also now a certifcated trainer in this area They home have received one complaint during the last twelve months where two aspects of an individual’s preferred daily living routines were not met with on a particular occasion. This matter is satisfactorily resolved. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 19 They would like to improve by facilitating regular relatives/residents meetings where they are able to voice any concerns, where the chair is not a member of staff and are seeking to organise this. They intend to ensure that a complaints book/log is placed in the main entrance area for people to more easily access and use. At this inspection we asked people if they know how to make a complaint and who to speak to if they are not happy. We also asked some people by way of our written survey the same. All people said they knew how to make a complaint and who to speak with if they are not happy. We spoke with staff about their responsibilities with regard to dealing with concerns and complaints and also in with regard to safeguarding vulnerable adults from harm or abuse. Staff are conversant with their responsibilities in respect of the above and confirmed that they receive instruction and training and that there is clear policy and procedural guidance in place in the home, which they can access. We looked at the home’s complaints record, which is properly maintained and also noted that the complaints and suggestions book is now located within the reception area, providing easier access for people. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 24 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home continues to be maintained, furnished and equipped to a high standard to the benefit of people who live and work there. EVIDENCE: At our last key inspection of this service we judged that people live in a safe, clean, comfortable and well-maintained environment, which provides purpose built accommodation to the satisfaction of service users accommodated. In our annual quality assurance questionnaire completed by the home they said that is a clean, hygienic and pleasant home, which is purpose built and is maintained to a good standard, with ongoing plans for its routine maintenance, repair and renewal. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 21 They say they always receive positive feedback from people about the standard of the environment. They also state that they have improved facilities over the last 12 months by way of ongoing redecoration and maintenance. They aim to make key improvements made possible by securing a government grant, which is to include replacement of all carpets, suitable in colour and pattern to assist those people with confusion and to replace conservatory furniture. Although they feel they could improve their storage facilities. At this inspection we looked at the private and communal areas of the home used by those people case tracked. We also looked at laundry facilities. We also spoke with people about their satisfaction with their environment and asked them if it is always kept fresh and clean, which we also asked people in our written survey. People said they were highly satisfied with their environment, which they said is always kept fresh and clean. People’s rooms are highly personalised and the home is maintained, furnished and decorated to a high standard. It provides a comfortable and homely environment with level access throughout and is suitably equipped in accordance with people’s assessed needs. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staff recruitment, induction, training and deployment are effectively managed in people’s best interests. EVIDENCE: At our last key inspection of this service we judged that people are effectively supported and protected by the numbers and skill mix of suitably trained staff and by the home’s recruitment practises. In our annual quality assurance questionnaire completed by the home they said that they have a high staff:resident ratio, particularly on the morning shift and also provider full hotel services cover seven days per week. (Kitchen, laundry and domestic). Additional staff are also in place to support the registered manager in administration and management, with dedicated activities staff and a physiotherapist who provides three hours per fortnight. They also say that they undergo a thorough recruitment process and a meticulous induction and training process and that seventeen out the the twenty three care staff employed have achieved NVQ level 2 in care or above. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 23 They say they have improved over the last twelve months by increased staffing levels, which are continually monitored, development of their staff training programme, ensuring tighter control over their recruitment process and associated record keeping. They feel they could improve their workforce planning and aim to continue to improve staff training opportunities. At this inspection we spoke with people about staff availability and we asked some people by written survey if staff is available when they need them. We also spoke with staff and some were surveyed in writing about the arrangements for their recruitment, induction, training and deployment and we examined related records. People accommodated said that staff are always available when they need them. They also made very positive comments about their care and support and staff attitudes and approaches towards them. Staff confirmed an effective recruitment and induction process and also training arrangements. They said there are usually enough staff to meet the needs of the people who use the service. Comments were to the effect that the only time there may be any difficulties are occasional and due to unexpected staff absence with no possibility of obtaining cover, which they said was not usual. Records that we examined in relation to the above are properly maintained and in good order. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 32, 33, 35, 37 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is very well managed and run in people’s best interests. EVIDENCE: At our last key inspection of this service we judged that here were clear improvements with regard to the management and administration of the home, with a re-establishment of its former consistent and robust approach in this area. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 25 We made one requirement and one recommendation in respect of ongoing quality assurance and monitoring systems, including the provision of an annual development plan for the home. These are complied with. In our annual quality assurance questionnaire completed by the home, they say that they have well established management arrangements, with clear lines of responsibility both internally and externally to the board of Trustees. Also, that the registered manager is well qualified and competent to undertake her role and is currently undertaking a post-graduate diploma in management studies. They say they promote an atmosphere which encourages people to make comments about the services provided by the home, that they promote people’s independence and also provide support as necessary with regard to the individual’s monies and financial arrangements. They also say that the home is safe and well maintained, that staff safe working practises are ensured and that they now have a thorough quality assurance programme in place At this inspection we spoke with the manager and staff about some of the arrangements for the management and administration of the home, including, quality assurance and monitoring, handling of people’s monies, communication, supervision and support and ensuring safe working practises. We also asked some staff in our written survey about some of those areas same, asked all what the service does well, made general observations as to the safety of the home during our inspection of the environment and examined records relating to the above. People said they are well supported to do their job and are conversant with their roles and responsibilities and those of others and felt that on the whole communications between staff about people who use the service work well. The arrangements for the management and handling of people’s monies are in accordance with recognised guidance. Safe staff working practises and the safe maintenance of the home is also well promoted. Comments received from staff with regard to what they think the service does well included, “ The care provided is excellent.” “I would particularly praise the food, which is well cooked, present and varied with choice.” “The general atmosphere is friendly yet efficient.” “We are always moving forward and constantly aiming to improve.” Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 26 “I think that (hopefully) we give a good all round service.” “We always have a long waiting list and constant enquiries for places here.” “We always respect people’s needs.” “Care is person centred and tailored to the individual.” “This is the best place I have worked.” Since the previous key inspection of this service management have developed a full quality assurance and monitoring system, which includes a full baseline and ongoing audit of all aspects of the service. From this an annual development/action plan is developed for the coming year and there are clear mechanisms for review. However, there is no formal mechanism for obtaining feedback from people about their satisfaction with the services the home provides. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 27 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 4 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X 4 X 4 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 2 X 3 X 3 3 Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 28 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. 1. 2. Refer to Standard OP1 OP33 Good Practice Recommendations Consideration should be given to providing the service guide/brochure in alternative formats, for people who are likely to benefit. Formal methods for seeking the views of people who use the service should be introduced/developed to assist in measuring the success of the home in meeting its service aims, objectives and statement of purpose. The results of any such formal consultations should be published/made available for people. Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thornhill House DS0000002093.V341576.R01.S.doc Version 5.2 Page 30 - 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!