Inspection on 15/05/07 for Thorpe House Nursing Home

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Thorpe House Nursing Home 23/01/08

Thorpe House Nursing Home 16/01/06

Thorpe House Nursing Home 13/09/05

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Thorpe House Nursing Home 22 Finthorpe Lane Almondbury Huddersfield West Yorkshire HD5 8TU Lead Inspector Karen Summers Key Unannounced Inspection 15th May 2007 08:30 Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 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 Thorpe House Nursing Home DS0000065036.V333648.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 and Care Homes for Adults 18 – 65*. 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. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thorpe House Nursing Home Address 22 Finthorpe Lane Almondbury Huddersfield West Yorkshire HD5 8TU 01484 300385 01484 300368 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) Thorpe House Nursing Home Limited Mr James A Lockwood Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (21) Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide accommodation and care for three named service users under the category of DE (dementia). 16th January 2006 Date of last inspection Brief Description of the Service: Thorpe House is a privately owned and managed care home registered to provide accommodation and nursing care for up to 21 adults with severe and enduring mental health needs. The establishment, a stone built period residence, is situated on the outskirts of the village of Almondbury. The property is set in extensive and well maintained gardens and grounds. Private accommodation consists of five double and eleven single bedrooms. Communal areas are spacious, comfortable and furnished and fitted to a good standard. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection and included an unannounced visit to the home on 15 May 2007, which took 7.5 hours. The nurse in charge, Mrs Rachel Croft, was present throughout the visit. During this visit, the inspector spoke to 5 people who live in the home and a number of staff. The inspector read care records, staff recruitment records, training records and staff supervision records, and also had a short tour of the home. There were 21 people living in the home on the day of this visit. To reflect the views of those who use the service, satisfaction surveys were sent to 10 people living at the home, 1 of which was returned and 10 relatives/ advocate/friends, 4 of which were returned; 1 to a local doctor which was returned and 10 to health care workers (Social workers, Community Psychiatric nurses), of which 4 were returned. Other information used in the inspection process included information supplied by Thorpe House Ltd, at the request of CSCI, about people who live at the home, staff who work there and how the home is run. Notifications received since the last inspection about incidents at the home have also been taken into account. The inspectors would like to thank those who contributed to the inspection, and also thank Mrs Croft, the staff and people who use the service, for their time and hospitality on the day of visit. What the service does well: A survey received from a Community Psychiatric nurse (CPN) stated, “Usually visit my client once monthly & staff keep me informed of any occurrences.” Another CPN stated, “The standard of care provided is high and it is individualised to meet my client’s needs and improve his quality of life.” A mental health social worker stated, “Thorpe House has been an excellent placement for my client…”’’ their mental health and physical health needs have been more than adequately met.” The doctor, in his survey, stated that the management of the home take appropriate decisions when they can no longer manage the care needs of the service user. The registered manager is a qualified mental health nurse and also has an NVQ level 4 in management. Records show that he and his staff attend regular Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 6 training and updates of existing training. The manager demonstrates a clear sense of direction and acts as a positive role model for the team. The home continues to be decorated to a good standard, and bedrooms are individualised to reflect the tastes of the individual people living there. People who were spoken with on the day commented that the home was well decorated, and one person said that the home is beautiful, with trees all the way up the drive and beautiful daffodils either side of the drive. What has improved since the last inspection? What they could do better: When staff from the home carry out their own assessment, that assessment is not recorded. They are advised to record their assessment as evidence that it has taken place. Even though people have their activities timetable written in their care records, the manager is advised to clearly state in each person’s records why they are encouraged to participate in the list of activities displayed on the notice board; cleaning shoes, writing individual weekly diary, choice of menu for the week, current affairs, assistance with finances, including the daily walks. The activities should also be agreed with the person as part of their individual care plans. One of the people who were spoken with said that they go out most days for a walk with staff. Another person said that they also went out for a daily walk, however, this person also said that they did not really like the walks but knew that it was good for them, as they felt better when they had been out. Three bedrooms were looked at, and in one of the bedrooms the walls were showing signs of wear and in need of redecoration. The headboard that staff said was stained with hair products needs to be replaced with a type that can be easily cleaned. The monitoring of the views of people who live at the home, and their relatives’ views, take place twice a year. The outcome of those views is discussed at the meetings that take place with people living in the home and also with visiting relatives. The manager is currently collating the most recent views of the people. When those views have been collated, they should be published and made available to visitors, prospective people who may use the service and people who live at the home. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 7 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. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2–5 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Prospective people to use the service are assessed prior to moving into the home and are able to visit to establish whether or not it is the right place for them. EVIDENCE: Prior to admission, the majority of people have a Community Care assessment and, where appropriate, the person wishing to live at the home would visit and meet other people living there, and staff. When staff from the home carry out their own assessment, that assessment is not recorded. They are advised to record their assessment as evidence that it has taken place. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 10 A survey received from a person who lives at the home commented that they received enough information before they moved in. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People know their assessed and changing needs and personal goals are reflected in their individual plan. People make decisions about their lives with assistance as needed. EVIDENCE: Care plans were comprehensive and record the action that needs to be taken by care staff, to ensure that the health and social care needs of the person using the service are met. Risk assessments and action to be taken had also been recorded, together with any restrictions on choice and freedom agreed Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 12 with the person. The documentation had been signed by the person or their representative, and had been drawn up with their involvement. It was evident from observing staff interaction with people living at the home that they knew each individual likes, dislikes and needs. The healthcare needs of people are met, evidence was seen of involvement from doctors, optician, dentist and other healthcare professionals where needed. A survey received from a Community Psychiatric nurse (CPN) stated, “Usually visit my client once monthly & staff keep me informed of any occurrences.” Another CPN stated, “The standard of care provided is high and it is individualised to meet my clients needs and improve his quality of life.” A mental health social worker stated, “Thorpe House has been an excellent placement for my client….their mental health and physical health needs have been more than adequately met.” A survey received from a parent of a person who lives at the home stated that they were pleased with their relative’s progress. The doctor, in his survey, stated that the management of the home take appropriate decisions when they can no longer manage the care needs of the service user. The doctor also said that any specialist advice is incorporated into the person’s care plan. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 – 17 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 14 People living in the home are able to maintain contact with their family and friends, they are able to have some choice over their lives and some social activities are provided. Food preferences of people have been taken into consideration when planning the meals and they enjoy a varied and healthy diet. EVIDENCE: People’s social interests and individual timetables of activities were recorded in their care plan and included information about their hobbies and interests. A list of activities to help people maintain and develop their daily life skills were displayed on a notice board in the hall and included writing their individual weekly diary, cleaning shoes, choice of menu for the week, current affairs, assistance with finances, etc. As part of the activities timetable, people are also encouraged to go out on a daily walk with the staff. On the day of the visit, a number of people were going out on a trip to Blackpool and some were going out on their daily walk. One of the people who were spoken with said that they go out most days for a walk with staff. Another person said that they also went out for a daily walk, however, this person also said that they did not really like the walks but knew that it was good for them, as they felt better when they had been out. Even though people have their activities timetable written in their care records, the manager is advised to clearly state in each person’s records why they are encouraged to participate in the list of activities displayed on the notice board, including the daily walks, and the activities should be agreed as part of people’s individual care plans. One person said that they go to the technical college twice a week where they enjoy doing art and have joined a discussion group. This person also said that they help around the home to do their laundry and ironing and they felt that this helped them regain their independence. A social worker stated on their survey, “Care appears rather basic with too much emphasis of walking in groups.” “Could be more individual activity, more stimulation.” The menus offered a variety of food and took account of individual people’s food preferences and specialised diet. Mrs Croft said that, although there was no one at this moment in time with any specific cultural needs, they would be catered for. People who were spoken with on the day said that the food was good. One person said, “Lovely cook, and the food is good.” Another person said that when someone has a birthday people have a cake, wine, -“food top class.” Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 – 20 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People’s physical and emotional health needs are met, and they receive personal support in the way they prefer and require. EVIDENCE: Records examined showed that individuals are supported to have regular health screening and access a range of health services. Clear, detailed information was available in the records about individuals’ healthcare needs. People confirmed that they are treated with dignity and respect, and that all personal and health care support is given in private. One person said that staff Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 16 support them to look after themselves. They also said that staff helped them to write their diary so that it could be referred to each day and would help them not feel panicky. Through discussion with staff and examination of records, it is evident that there is an awareness of the changing needs of the people living at the home, and that all staff have up to date training to ensure that they have the knowledge to meet the needs of the people. Medicine management at the home is good and there are good systems for the auditing of medication. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People living at the home, and their relatives and friends, can be confident that their complaints will be listened to, taken seriously and acted upon. People are protected from abuse. EVIDENCE: There is a complaints procedure and a procedure for the protection of vulnerable adults, including whistle blowing, and staff have had training in abuse awareness and control and restraint. The survey returned from a person who lives at the home stated that they knew who to speak with if they were not happy, and they knew how to make a complaint. Two out of three relatives were aware of the home’s complaints procedure, and the doctor’s survey said that they had not received any complaints about the home. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People at the home live in a well-maintained and homely environment. The premises are clean and systems are in place to control the spread of infection. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home continues to be decorated to a good standard, and bedrooms are all individualised to reflect the tastes of the individual people living there. People who were spoken with on the day commented that the home was well decorated, and one person said that the home is beautiful, with trees all the way up the drive and beautiful daffodils either side of the drive. Three bedrooms were looked at and, in one of the bedrooms the walls were showing signs of wear and in need of redecoration. The headboard that staff said was stained with hair products needs to be replaced with a type that can be easily cleaned. Since the last inspection visit, new carpets have been laid in the small lounge, downstairs corridors, staircase and first floor corridors and a number of bedrooms have been redecorated. The home is kept clean and there are policies and procedures that refer to the control of infection. The surveys stated that the home was always fresh and clean. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People living at the home benefit from being supported by qualified, competent and supervised staff, that have had all the necessary checks before working with people so that they are kept safe. EVIDENCE: There were sufficient numbers and skill mix of staff on duty, day and night, to care for the number of service users. Two out of three relatives’ surveys state there are always sufficient staff on duty, and the third was not sure. The Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 21 doctor’s survey states that there is always a senior member of staff to confer with. More that 72 of care staff have an NVQ level 2 or equivalent and there is a qualified nurse on duty 24 hours a day. Staff recruitment files contained the relevant information and documentation. New staff have induction training, and all staff have supervision a minimum of six times a year. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 23 Thorpe House is a well managed home that has good safety standards. However, although some quality monitoring takes place, a more formal approach to show the outcome of the monitoring would improve the service in this area. EVIDENCE: The registered manager is a qualified mental health nurse and also has an NVQ level 4 in management. Records show that he and his staff attend regular training, and updates of existing training. The manager demonstrates a clear sense of direction and acts as a positive role model for the team. Meetings with people who live at the home take place every two weeks and minutes are recorded. The monitoring of the views of people who live at the home, and their relatives’ views, take place twice a year. The outcome of those views is discussed at the people’s meeting, and also with visiting relatives. The manager is currently collating the most recent views of the people. When those views have been collated, they should be published and made available to visitors, prospective people to use the service and people who live at the home. The information provided to CSCI before this visit indicates that maintenance of equipment and health and safety checks have been carried out at the required intervals. Records also show that staff have received relevant training in this area. Records relating to health and safety were in good order and demonstrate that the necessary action is taken to keep people and staff safe. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 2 40 X 41 X 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thorpe House Nursing Home Score 3 3 3 3 DS0000065036.V333648.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard YA12 Good Practice Recommendations It should be clearly recorded in each person’s care plan why they are encouraged to participate in the list of activities displayed on the notice board and the activities should be agreed with the person as part of their individual care plans. Rooms that are showing signs of wear should be redecorated. The monitoring of the views of people who live at the home, and their relatives, should be published and made available to visitors, as well as prospective people to use the service and people who live at the home. 2. 3. YA24 YA39 Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. Thorpe House Nursing Home DS0000065036.V333648.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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