This inspection was carried out on 3rd October 2005.
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.
CARE HOMES FOR OLDER PEOPLE
Thorpe House Nursing and Residential Home Knightthorpe Road Loughborough Leicestershire LE11 4JS Lead Inspector
Debbie Williams Unannounced 3 of October 2005 10:00
rd 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 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. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Thorpe House Nursing & Residential Home Address Knightthorpe Road Loughborough Leicestershire LE11 4JS 01509 219878 01509 262710 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Rushcliffe Care Limited Mrs Diana Mary Squire Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (50), Physical disability of places over 65 years of age (50), Terminally ill over 65 years of age (2) Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 18/3/05 Brief Description of the Service: Thorpe House Nursing and Residential Care home is a purpose built home situated in the Thorpe Acre area of Loughborough Leicestershire. The home is registered for fifty places which include physical disability (over 65 years of age) old age and two registered places for terminal illness. Thorpe House is owned by Rushcliffe Care Limited.It is located close to the centre of the town within a ten-minute car journey and is situated on a bus route. The Loughborough community hospital is sited approximately half a mile from the home.The home’s accommodation is situated on two floors that can be accessed by a passenger lift.The large garden is laid to lawn and is surrounded by flowerbeds and mature trees. The location of the home is on a main road within a residential area. Facilities close by include all the attractions of a busy village, close by are a local church, a variety of shops and a number of social amenities including several pubs and a social club. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over three and a half hours and was facilitated by the home’s registered manager. The inspector selected four service users and tracked the care they receive through review of their records, discussion with them (where possible), the care staff and observation of care practices. The inspector spoke with staff members regarding training and support. The registered manager and other staff spoken with facilitated the inspection in a positive manner and responded positively to requirements and recommendations made. What the service does well: What has improved since the last inspection?
Since the last inspection requirements and recommendations made have been met. The staff had taken appropriate action regarding the placement of one resident at the home and appropriate action had been taken. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 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 standard(s) 3 Assessment procedures are robust so ensuring that all needs are identified and can be met. EVIDENCE: Assessment records for four residents were inspected; these contained all necessary assessment information and risk assessments. Assessments are carried out prior to admission by the homes registered manager or by a senior manager. Residents and visitors spoken with confirmed that assessments of their needs had been carried out prior to admission. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 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 standard(s) 7, 9 and 10 Some residents did not feel they were always treated with respect and dignity and therefore residents personal and social care needs were not always being met. Medication policies and procedures appeared in good order and afforded protection for residents. EVIDENCE: Care plans for four case tracked residents were inspected and appeared to be meeting all assessed needs. Quick reference care plans were also used. Medication administration records for the four case tracked residents were inspected and appeared in good order. Medication is administered by qualified nurses. Residents spoken with as part of the case tracking process felt that some staff spoke to them in an inappropriate manner and did not always treat them with respect and courtesy. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 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 standard(s) 12 and 13 Activities on offer did not fully satisfy the social and recreational needs of some residents. Residents were able to maintain contact with their friends and relatives. EVIDENCE: Two of the residents spoken with did not feel that the social and recreational activities on offer matched their needs or expectation. One resident felt they would like more opportunity to go out of the home shopping etc. At the time of this inspection the home were trying to recruit an activities organiser and had arranged a programme of activities over the summer such as games and residents being taken out on one occasion. New patio furniture had also been purchased for residents use during warmer weather. Residents spoken with confirmed their visitors could visit the home at any time and could be seen in private. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 Complaints and adult protection policies were robust and afforded protection and minimised risk to residents accommodated. EVIDENCE: The home has comprehensive adult protection and complaints procedures in place. Staff members spoken with were aware of the correct procedures to follow in the event of suspected abuse. Residents spoken with said they would feel comfortable making a complaint to the registered manager and were aware of the home’s complaint procedures. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 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 standard(s) 19 and 26 All areas of the home inspected were found to be well maintained, clean and appeared hygienic. EVIDENCE: A programme of routine maintenance was in place. The home employs a maintenance person, records of routine maintenance and risk assessments were seen. Residents spoken with were satisfied with the cleanliness and maintenance of all communal and private accommodation. All areas of the home inspected including outside areas appeared accessible and comfortable. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 On the basis of evidence gathered at the time of this inspection, it could not demonstrated fully that staff competency and numbers were meeting the needs of residents accommodated. EVIDENCE: At the time of this inspection there were forty residents living in the home. The home was staffed with six staff in the morning, five in the afternoon and three at night. At least one qualified nurse was included within these numbers. The registered manager said that staffing levels would be increased if occupancy or dependency levels increased. Residents spoken with said that there were occasions when staff seemed very busy and could not provide the care they required at the times that suited their needs. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The health and safety of residents and staff was promoted and protected. EVIDENCE: The home has comprehensive health and safety policies and procedures in place. Staff spoken with had received health and safety training. Records of risk assessments, maintenance procedures and safety checks were inspected. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 Page 16 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. 1. Standard 10 Regulation 13 Requirement Staff must receive instruction and training regarding the requirement to treat residents with respect and dignity. Staff should also revisit the abuse policy with particular reference to institutional abuse. Review staffing levels to ensure that staff are able to meet the needs of residents accomodated Review the range and availability of socail and recreational activities on offer to ensure these meet the needs and expectations of residents accomodated. Timescale for action October 30th 2005 2. 3. 27 12 18 13 October 30th 2005 November 30th 2005 4. 5. 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 38 Good Practice Recommendations Review and update the homes fire risk assessment. Thorpe House Nursing and Residential Home C51 C01 S1928 Thorpe House NR V247533 031005 Stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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