Inspection on 07/12/05 for Thornhill House

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 19/09/07

Thornhill House 24/01/07

Thornhill House 10/10/06

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 Unannounced Inspection 7th December 2005 10:00 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.V271664.R01.S.doc Version 5.0 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.V271664.R01.S.doc Version 5.0 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 Alison Heather Ferguson Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 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) under the category DE,E - not Transferable to any other service users, other than those as named. 13th June 2005 Date of last inspection Brief Description of the Service: Thornhill House provides nursing and personal care and support for up to 16 older persons, including two named residents with dementia by way of a variation granted to the home’s registration since the previous inspection. It is a purpose built, single storey accommodation, located in the village of Great Longstone approximately 3 miles north east of the market town of Bakewell. The home is operated from the John Thornhill Memorial Trust, which is a registered charity. It provides all single room accommodation, each having an en suite facility. There are also separate communal bathing and toilet facilities and central kitchen and laundry facilities. The home is suitably equipped to meet the needs of residents who may have physical disabilities, including an emergency call system in all areas accessed by them. Gardens are well maintained and provide level access together with seating. There is also adequate car parking provision. The registered manager has been in post for one year, although was due to terminate her employment. The post had however, been recruited to with acting management arrangements for the interim period. Care and support to service users is delivered by a team of nursing, care and hotel services staff. Close links are established with the local community with a substantial number of volunteers providing additional support. Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection was on the staffing arrangements and management systems in the home. Discussions were also held with a sample of staff in relation to those systems and arrangements and the Inspector also spoke generally with service users about the home and its service provision. What the service does well: What has improved since the last inspection? What they could do better: Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 6 Registered Nurses, who are responsible for the management and administration of medicines to residents, must ensure that they do so in accordance with the Nursing and Midwifery Council’s codes of practise for medicines administration and management, records and record keeping and accountability. The registered persons must ensure that the arrangements for the recruitment and induction of all staff are in accordance with recognised standards of practise and that records reflect this. The registered persons should ensure that all policy and procedural guidance provided for staff working at the home is regularly reviewed and that management reviews (undertaken at appropriate intervals) are developed to include all aspects of care and service provision, including items raised under this section. 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. Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 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 the following standard(s): 9 Registered Nurses employed in the home, who are responsible for the management and administration of medicines were not always practising in this area in accordance with identified codes of professional nursing practise. The safety of the administration of medicines was therefore compromised. EVIDENCE: At the previous inspection for this service a number of requirements were identified in relation to the arrangements for the management and administration of medicines. Some of these were met. However, examination of medicines administration record (MAR) sheets, revealed significant deficits in the standards of recording, which brought into question the administration practises of the nursing staff responsible for the management and administration of medicines. A medicines refrigerator had been purchased since the previous inspection, however, there was no maximum and minimum thermometer provided and the daily temperatures of the refrigerator were not being monitored and recorded. Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 10 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): The standards in this section were not assessed on this occasion. EVIDENCE: Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 11 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): The standards in this section were not assessed on this occasion. EVIDENCE: Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 12 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 All areas of the home, which were seen during the inspection were wellmaintained, clean and comfortable, odour free and suitably equipped. EVIDENCE: Although a full inspection of the building was not undertaken on this occasion, a number of communal areas were visited, together with some individual accommodation. The Health and Safety Executive had visited the inspected the home since the previous inspection. The manager advised of the outcome of this visit. Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 13 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 Service users have the support of a cohesive, reliable and well-intentioned staff team, of sufficient number on each shift. However, deficits in the arrangements for staff recruitment and induction undermine the potential efficacy of that staff team. EVIDENCE: Details of staff employed were provided, together with staff duty rotas and the arrangements for the recruitment, induction, training and support of staff were discussed with the manager and staff. Associated records were also examined and the Inspector spoke with some residents and relatives about the arrangements for staffing in respect of the care and support they received. There were two more recent care staff starters, who had commenced working in the home before proper checks had been confirmed. This was discussed with the manager and raised as a serious concern separately in writing with the registered persons during the inspection. Although some records of staff training were kept, there was no clear record of structured induction training for each staff member in accordance with recognised training standards. Discussions with staff indicated that the approach to individual staff induction was not properly structured or planned in accordance with recognised training standards, although staff were being orientated to the home and had received core health and safety training. Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 14 Records were kept of individual staff supervision sessions, which included identification of some aspects of their training and development, although there were no separate individual training and development plans in place for each staff member. Policies and procedures were examined in relation to the above. Some of these had not been reviewed or updated for some time. (See also management section of this report). Discussions with staff and service users and examination of staff rotas indicated that there was generally sufficient staff numbers on each shift to meet with service users care and support needs. Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 15 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, 32, 33, 34, 35, 36, 37 & 38 Overall there were satisfactory arrangements in place to promote service users rights, protection and best interests. However, deficits identified in standards of records and record keeping (staff recruitment and induction and medicines), indicate that there are aspects of practise, which require a full management review to ensure that the health and safety of service users is fully promoted. EVIDENCE: The registered manager was due to leave her employment in the home. The arrangements for management cover whilst recruitment to this post was being undertaken were discussed with the manager following formal written notification to the Commission. The arrangements for the management and administration of service users monies, where applicable were discussed and records examined. These were satisfactory. Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 16 Records for the monthly management reviews as undertaken by the registered manager were examined and discussed with her and recent reports provided by the registered provider following their monthly, unannounced visits to the home were also examined. Mechanisms for consultation with service users and their representatives were also discussed. A number of the home’s policies and procedures were examined in relation to the staffing and management of the home. (See staffing section of this report). A number of records were also examined in relation to the management and staffing of the home, together with medicines records. Comments have been made under Section 2 – Health and Personal Care section of this report in relation to medicines administration records, which were deficient. Deficits were also identified in terms of staff recruitment and induction records – see Section 6 - Staffing section of this report. In all other respects, records inspected were safely stored and properly kept. The arrangements for staff core health and safety training were discussed with the manager and staff and records were examined in respect of this. These were satisfactory. Details of the annual maintenance of equipment were provided by way of up to date certification, with the exception of the Landlords gas safety certificate. The manager advised that this had recently been undertaken. Areas of the building seen were clean and safe and free from noticeable hazards. The system for the reporting and recording of accidents and untoward incidents was also examined and was satisfactory. Adequate liability insurance cover for the home was evidenced by way of up to date certification for the home, which was openly displayed. Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 3 3 3 2 3 Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 18 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 OP3 Regulation 14(1)(2) Requirement Timescale for action 31/07/05 2 OP9 13(2)& 17(1), S 3 3 OP9 13(2) 4 OP29 19 Residents recorded individual needs assessments must include all relevant information. (NB Not assessed on this occasion – requirement made at previous inspection 13/06/05. The registered persons must 31/01/06 ensure that the arrangements for the administration of medicines are undertaken in accordance with recognised standards of practise – to be administered as prescribed and signed as administered or the proper coded reason recorded indicating the reason a medicine was not given to any service user. The registered persons must 31/01/06 ensure that the temperature of the medicines fridge is monitored and recorded daily using and minimum and maximum thermometer. The registered person shall not 07/01/06 allow any person to work at the home until satisfactory confirmation of their fitness has been determined. NB Immediate DS0000002093.V271664.R01.S.doc Version 5.0 Thornhill House Page 19 5 OP30 17, 18 6 OP33 24 6 OP33 24 7 OP37 17 requirement for action raised in writing during inspection. All staff must receive structured induction training in accordance with current recognised training standards and individual records kept of that induction for each staff member. Policies, procedures and practices must be regularly reviewed in light of changing legislation and good practice advice from relevant bodes and organisations. Management reviews undertaken at appropriate intervals (quality assurance) must include that relating to staff recruitment and induction and medicines administration records and practises. Records required by regulation must be kept up to date and accurate. (In this instance records relating to staff recruitment and induction and medicines administration). 28/02/06 28/03/06 28/03/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations Staff responsible must ensure that they sign and date all needs assessment and care planning records on their completion. (NB Not assessed on this occasion – from previous inspection 13/06/05). Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Thornhill House DS0000002093.V271664.R01.S.doc Version 5.0 Page 21 - 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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