Inspection on 14/05/09 for Thornlea

This inspection was carried out on 14th May 2009.

CQC found this care home to be providing an Adequate service.

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

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Thornlea 198 Charlestown Road Blackley Manchester M9 7ED Lead Inspector Sue Jennings Key Unannounced Inspection 14th May 2009 09:30 DS0000072946.V375389.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornlea Address 198 Charlestown Road Blackley Manchester M9 7ED 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) 0161 740 8378 0161 740 7598 Inspirit Care Limited Mrs Michelle Marie Honeyford Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 40 Date of last inspection This is the first inspection of this home. Brief Description of the Service: Thornlea is a purpose built care home managed and registered in the name of Inspirit Care Limited a subsidiary of Community Integrated Care (“CIC”), a registered charity. The home provides accommodation and personal care for up to 40 people. The home is in the north of Manchester City centre. It is located close to public transport links into the city centre, local markets and shopping facilities. The home is set in its own grounds with car parking facilities to the side and on the main road at the front of the building. The current range of accommodation fees charged is between £382. 88 and £455.00. Those items not included in the fees are: Newspapers, hairdressing, private treatments, some transport costs. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by us (the Care Quality Commission) in relation to this home prior to visiting the home. The site visit was unannounced and took place over the course of 7 hours on Thursday 14th May 2009. During the course of our visit to Thornlea we spent time talking to people who live at the home, visitors the manager and care staff to find out their views of the home. We spent time looking at records. We looked at the care files of people living at the home and staff files. We also walked round the home and looked at communal areas and a sample of bedrooms. This visit was just one part of the inspection process. Other information received was also looked at. Some weeks before the visit the manager was asked to complete a questionnaire called an Annual Quality Assurance Assessment (AQAA) telling us what they thought they did well, what they needed to do better and to give us up to date information about the service provided. This helps us to determine if the management of the home see the service they provide in the same way we do and if our judgements are consistent with homeowners or managers. This service was recently re registered with us and therefore is classed as a new service with this being the first inspection. No references will be made to previous inspections of this home. References to we or us throughout this report represent the Care Quality Commission. What the service does well: The home provides enough information to people thinking about moving in. They told us that assessments of peoples needs are carried out before people move in to make sure the home can meet their needs. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 6 Recruitment is robust and makes sure that staff are safe to work with vulnerable residents. They have good working relationships with community nurses and GP’s. They told us they meet with residents at regular intervals to ask their views of the service. They have a structured activities programme, with a dedicated activities organiser. What has improved since the last inspection? What they could do better: The carpet in the designated smoking area was puckered and posed a potential trip hazard for people using the room. Recording in daily records was repetitive and did not clearly reflect what care had been given to people. There was no clear audit trail of care plan reviews and some risk assessments had not been updated. Two of the care plans we saw did not include any information about what personal care the individual needed. Staff files contained copies of documents but there was no evidence that the originals had been seen. Some of the health and safety training was outdated. We did not see that a recent fire drill had been carried out. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Thornlea DS0000072946.V375389.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 Thornlea DS0000072946.V375389.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given enough information about the home and have a needs assessment before moving in so that they know the staff can meet their needs. EVIDENCE: The manager told us that they or a senior care worker usually visited prospective service users at home or in hospital. This was to carry out an assessment of their care needs. The manager told us they also receive a copy of the care manager’s assessment. Once a person is admitted a care plan is written using the information gathered during these assessments. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 10 We saw a sample of care plans that had pre-admission assessments. The assessments were detailed and gave enough information to write the care plan. We saw that one person appeared to be inappropriately placed at the home. We saw that the care manager/nurses assessment identified the need for an EMI residential placement where staff have an understanding of mental health problems. The manager told us they had requested an urgent review of this placement. We spoke to people living at the home they told us that they were invited to visit the home before making a decision to move in. One resident told us “I have come from one of the other homes that is closing down I came to visit see what it is like here” another told us “this is the third home I have been to all the others have closed and I have had to move”. This home does not provide intermediate care. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s needs are generally met by staff and medication administration practices safeguarded people from harm. Care plans did not provide enough detail about people’s care needs or the action needed to meet needs. EVIDENCE: We saw a sample of care plans. We saw that care plans were not very detailed and did not give enough information about the action needed to meet people’s needs in relation to health, personal and social care needs. We saw a document in the care plans that had been signed and dated to indicate the care plans were reviewed on a monthly basis. Despite this we saw that two of the care plans sampled did not give any information about what level of support people needed. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 12 For example there was no information about what help people needed with washing and dressing, pressure relief or any information about oral hygiene. A recommendation is made that a thorough audit of care plans be carried out to make sure they clearly detail people’s care needs and the action required to meet needs. This is to make sure that people are receiving the most appropriate level of care. We saw that one person had been assessed as at high risk of developing pressure sores. We did not see a risk assessment in the care plan to show what was needed to minimise this risk. A requirement is made that where a risk is identified there must be a detailed risk assessment in place to identify how best to minimise risks to people. Recording in daily records was repetitive and did not clearly reflect what care had been given to people each day. We saw on one person’s care plan the daily record of care had only been completed by night staff. The records contained entries such as ‘assisted to bed’ and ‘appears to have slept well’. We saw a number of dates when no entries had been made into individuals’ daily record by the day staff, the people who provide the majority of care. A recommendation is made that daily records be completed after each shift and fully reflect the care being delivered. The daily records in one person’s care plan stated that a district nurse had been and that the person’s blood sugar levels were high. The district nurse had requested that this person did not eat any sweet foods. This information was not mentioned again in the daily notes. This means that we could not see if the district nurse’s instructions were being carried out. We saw that the professional assessment for one person clearly identifies the need for an ‘EMI residential placement where staff have an understanding of mental health problems’. The home is not registered to provide support to people whose primary care need is related to mental ill health. This person’s behaviour was clearly impacting on other people living at the home. In addition their own care needs were not being met. The manager told us that they had requested a review and were waiting for the GP to visit. A recommendation was made that staffing levels be reviewed to take into account the additional support needed until a re-assessment can be carried out. We saw that deliveries and disposal of waste medication had been signed for. This gives a full audit trial to check that people are receiving their medication when they need it. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 13 Medication was dispensed into a blister pack monitored dosage system and stored in a locked trolley. Sample signatures and initials were recorded of all staff responsible for administering medication. We looked at a sample of Medication Administration Sheets (MAR). We saw that these were up to date. We saw that there were some gaps in recording but in these instances the medication had not been administered. We carried out a medication count and found the number of tablets tallied with the number of initials on the sheet and that where we saw gaps in the record the tablets were still in the blister pack. We saw one person’s medication record for the 7th and 8th May 2009 that highlighted that one medication Salbutomol was out of stock. We saw that this medication had been signed as given at 16.30 and again at 20.30. This leads us to believe that the medication is not being signed for at the point of administration. It is recommended that where medication is refused or not administered the reason for this should be recorded on the reverse of the MAR sheet. A recommendation is also made that medication is signed for as it is given to the person. We saw that people living at the home were registered with local General Practitioners and had access to visiting healthcare professionals e.g., Dietician, Chiropody, Dentistry and Ophthalmology. This means that people had access to appropriate health services necessary to meet their health care needs. We spoke to people who live at the home. One person told us “the staff are very good they work really hard” another said “I am quite happy here I have everything I need and the staff are all very nice”. Another person told us that staff were polite and treated them with respect. Comments included “they are very good” and “all very helpful”. During our visit to Thornlea there was a new admission. This person told us that they had moved three times due to home closures and that it was “very upsetting”. We saw the staff welcoming them into the home and showing them the toilets and communal areas. We saw that staff were aware that this was a difficult time for this person and spent a lot of time helping them to settle in. We saw that each member of staff took time to introduce themselves and ask if the person needed anything. We saw that staff were very busy during the site visit. Despite this we saw some good care practices. We saw staff observing people and offering assistance in a way that most suited the person. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 14 Staff chatted to people as they passed them in the corridor or when they walked past people sitting in chairs. Staff seemed kind, patient and friendly with everybody. It was obvious that the staff knew people well. Thornlea DS0000072946.V375389.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a good range of activities and a variety of home cooked food. EVIDENCE: We saw staff welcoming visitors into the home. There was an open visiting policy and residents were able to see visitors in one of the lounges or in the privacy of their own rooms if preferred. The menus were displayed in the dining room so that residents knew what the meal choices were for the day. One person told us “I have just had my dinner, it was very lovely”. There was a choice of food at each mealtime and any reasonable alternative to the menu is available on request. The meal on the day of the site visit was gammon steak or cheese flan served with beans, boiled potatoes and cabbage with fresh fruit or apple crumble for sweet. We saw that staff helped those people who needed assistance at mealtimes. This was done with sensitivity maintaining the person’s dignity. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 16 People were offered a choice of tea, coffee or soft drinks to have with their lunch. The meals were well presented and of ample portions. The evening meal was sausages or beef burgers on a bun or a selection of sandwiches with bananas and custard for sweet. One person told us that “the meals are really nice but tea is too early it is served not long after lunch”. Another person told us “we have boiled eggs for breakfast on Tuesdays and Thursdays” and “I have the small shreddies I used to have them before I came here, then I had toast”. One person told us “it is gammon for tea, I like to put it onto bread and have a sandwich the staff know I like that”. Other people told us there is “always something different” and “good choices and plenty”. We saw that lunch was served at around midday. Staff told us that tea was served from about 4pm. A supper of hot milky drinks, tea and coffee with a choice of sandwiches or biscuits was provided in the evening. We saw people sat reading, watching TV or resting in their rooms after lunch. A visitor told us “we are able to come and visit at any time they don’t mind”. We saw there were a number of different in-house recreational activities on offer. An activities programme was in place that included details of activities and visiting entertainers planned. A music quiz was being held on the morning of our visit to Thornlea and a sing-a-long was planned for the afternoon. A hairdresser visited the home. This was a well used facility and people were able to sit and chat whilst having their hair cut and set. Ministers from local churches visited the home on a regular basis. The manager told us that arrangements would be made to support people from other religious backgrounds as and when required. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaint’s procedure is clear and accessible. People who use the service and their representatives’ feel listened to and taken seriously. EVIDENCE: There are suitable procedures in place for dealing with complaints. The complaints policy and procedure is part of the guide for the people living there. We saw that there had been no complaints logged at the home since the last inspection. We saw that previous complaints were dealt with in line with the home’s complaint policy. There are internal policies and procedures for the Protection of Vulnerable Adults (POVA) and a copy of the local procedures was also seen to be available. There have been no recent allegations of abuse. We spoke to staff that told us that they have received training that teaches them how to recognise and report abuse. One told us “I would report to the manager or a senior member of staff”. Another said “I would make sure the resident was OK then tell the manager”. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 18 Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment and standard of hygiene was generally well maintained both internally and externally. EVIDENCE: We walked around the home and saw that the communal areas were generally comfortable and well-maintained. There was laminate flooring in many areas of the home. The dining room was bright and airy. The manager told us that a major refurbishment of the home is due to start in August 2009 through until October 2009. This was to include roof repairs, replacement windows, new furniture and carpets. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 20 We saw that there were satisfactory numbers of housekeeping staff to keep the home clean. Bedrooms are individualised to people’s preferences. People told us they were able to bring personal items, including furniture, with them on admission and are able to have a private telephone line should they wish. People told us they were generally happy with the environment. One person told us “they work really hard to keep it clean” and “I am happy with how my room is kept clean”. There was a designated smoking room. Cigarette smoke could be smelt in the surrounding areas. The manager told us that people switch off the extractor fan because it is old and noisy. It was recommended that a new fan be fitted to reduce the effects of smoke on other people living at and visitors to the home. We also saw that the carpet in this room was puckered in places and posed a potential trip hazard to people using the room. It was recommended that the carpet in the designated smoking room be replaced as soon as possible. The homes main laundry was situated on the ground floor corridor and contained appropriate washing and drying facilities. Dirty lined was transferred to the laundry in coded bins and soiled lined is transferred separately. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by the home’s recruitment procedures. Staffing levels did not fully meet the needs of the people living at Thornlea. EVIDENCE: We saw that staff were very busy. We spoke to staff and they told us that new people were being admitted to the home but the staff numbers had not increased. The manager told us that these had previously been reduced because there had been fewer people living at the home. We saw catering staff literally running around and trying to help care staff to support people with their meals during lunchtime. We saw that staff were providing a higher level of support to one person who was waiting for a re-assessment of needs. We also saw that staff offered a higher level of support to the person who had been admitted that morning. This person had been unsettled because they had to move from their previous home. All of these things had the potential to place both the people living at the home and staff at risk. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 22 We saw that even though staff were stretched during busy times. They approached people with respect and helped to maintain a calm and relaxed environment for people to enjoy their meals. We also saw that there was a good relationship between people living at the home and the staff group. People living at the home told us “the staff are really good” another said “they are really busy I don’t like to bother them”. We spoke to a number of the staff on duty. Many of them felt that they were rushing around all the time and not meeting peoples needs as well as they should. This was mainly due to more people being admitted to the home but no increase in staffing levels. One member of staff told us “I can’t go on at this pace for much longer we need more staff, the numbers have gone up but they have not done anything about it”. Another person told us “I feel as though I am just rushing past the people who live here, there is no time for them, people are being rushed and it is wrong”. Staff surveys received also indicated that there were not enough staff to meet the needs of people living at the home. The manager told us that staffing hours were under review. A requirement is made that staffing numbers be reviewed and where necessary increased to make sure they meet the needs of people living at the home. The manager reported that staff supervision was provided and that all staff had an induction period. Training needs were identified during supervision and the home provided ongoing refresher training. We saw that staff meetings were being held on a regular basis and minutes kept. We saw that staff were required to sign to state that they have read and understood the policies and procedures. We spoke to several care staff. They told us that they had access to a range of training. We saw that training in relation to manual handling, medication, fire safety, first aid, and Protection of Vulnerable Adults had been provided. Staff have the opportunity to complete a National Vocational Qualification (NVQ) in care and currently more than half the care staff hold the NVQ level 2 in care. We saw that some training in relation to health and safety was dated 2007. It is recommended that training files are reviewed and where necessary updated training provided. We saw a sample of staff files. These showed us that staff were given a copy of their job description detailing their roles and responsibilities. We saw that references were taken up. We saw that each member of staff had a Criminal Records Bureau (CRB) check and a check against the Protection of Vulnerable Adults list (POVA) to make sure they were safe to work with vulnerable people. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 23 We saw that documents had been copied. This is to check the person’s identity and proof of address. It was recommended that where copies of documents had been taken as proof of identity these should be signed and dated to show the originals have been seen. Thornlea DS0000072946.V375389.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed and operated in the best interests of the people living at the home. EVIDENCE: The manager has a number of years experience running a care service for older people. Staff told us “the manager is very good we can speak to her anytime”. We spoke with the manager and she showed a good understanding of what improvements are needed. We saw samples of people’s financial records. We saw that receipts were kept for any money spent on behalf of people living at the home. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 25 Computer records are also kept in relation to people’s finances. We did not see any formal agreements that the home can manage people’s financial affairs. The manager was aware of the mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. A recommendation is made that the home develop a formal agreement between people living at the home or their representatives, that staff can access people’s monies to buy personal items for them. A system of staff supervision is in place and we saw completed minutes in staff files. We spoke to staff who told us that they had supervision with a manager on a regular basis. We saw a sample of the homes records. The manager told us that it is the policy of the home to carry out a fire drill every month. The log of fire drills was out of date the last recorded drill being February 2009. The manager showed us an entry in the diary that indicated a drill was planned for May 2009 but there was no evidence to show this had actually been carried out. A recommendation is made that a fire drill be carried out as soon as possible. This is necessary to make sure all staff and people living at the home know what to do in the event of a fire. It is particularly important for those people newly admitted. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 26 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? 1st 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 OP7 Regulation 13 (4)(c) Requirement A requirement is made that where a risk to an individual is identified there must be a detailed risk assessment in place to identify how best to minimise risks to people. Staffing numbers must be reviewed and where necessary increased to make sure they meet the needs of people living at the home. Timescale for action 20/06/09 2. OP27 18 (1)(a) 20/06/09 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 OP7 Good Practice Recommendations A recommendation is made that a full audit of care plans be carried out to make sure they clearly detail people’s care needs and the action required to meet needs. Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 28 2. 3. 4. OP7 OP7 OP9 A recommendation is made that daily records reflect the care being delivered. A recommendation is made that daily records be completed after each shift and fully reflect the care being delivered. It is recommended that where medication is refused or not administered the reason for this should be recorded on the reverse of the MAR sheet. It was recommended that the carpet in the designated smoking room be replaced as soon as possible. It is also recommended that a new fan be fitted to reduce the effects of cigarette smoke on other people in the home. 5. OP19 6. OP30 It is recommended that training files are reviewed and where necessary updated training provided. It is also recommended that copied documents confirming the identity of staff be signed and dated to show the originals have been seen. A recommendation is made that the home develop a formal agreement between people living at the home or their representatives, that staff can access people’s monies to buy personal items for them. A recommendation is made that a fire drill be carried out as soon as possible. 7. OP35 8. OP38 Thornlea DS0000072946.V375389.R01.S.doc Version 5.2 Page 29 Care Quality Commission North West Region PO Box 1245 Newcastle upon Tyne NE99 5AF National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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