Inspection on 21/12/06 for Thurn Court

This inspection was carried out on 21st December 2006.

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

Thurn Court 09/12/08

Thurn Court 03/11/05

Thurn Court 06/04/05

Thurn Court 10/01/05

Thurn Court 27/07/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Thurncourt Thurncourt Road Thurnby Lodge Leicester Leicestershire LE5 2NJ Lead Inspector Rajshree Mistry Key Unannounced Inspection 21st December 2006 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thurncourt Address Thurncourt Road Thurnby Lodge Leicester Leicestershire LE5 2NJ 0116 2413126 0116 2418848 socis211@leicester.gov.uk socis209@leicester.gov.uk Leicester City Council 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) Mr Rajesh Parekh Care Home 38 Category(ies) of Dementia (20), Dementia - over 65 years of age registration, with number (20), Mental disorder, excluding learning of places disability or dementia (20), Mental Disorder, excluding learning disability or dementia - over 65 years of age (20), Old age, not falling within any other category (38), Physical disability (5), Physical disability over 65 years of age (5), Sensory impairment (10), Sensory Impairment over 65 years of age (10) Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person falling within the categories/combined categories DE, DE/E, MD and MD(E) should be admitted into Thurn Court where there are 20 persons who fall within categories/combined categories DE, DE(E), MD and MD(E) already accommodated within the home. No person falling within the categories/combined categories PD and PD(E) should be admitted into Thurn Court where there are 5 persons of categories/combined categories PD and PD(E) already accommodated within the home No person falling within the categories/combined categories SI and SI(E) should be admitted into Thurn Court where there are 10 persons of categories/combined categories SI and SI(E) already accommodated within the home No person falling under 60 years of age who fall within categories/combined categories DE, MD and SI should be accommodated within Thurn Court No person falling within category OP should be admitted into Thurn Court where there are 38 persons of category OP already accommodated within the home The maximum number of persons to be accommodated at Thurn Court is 38. 3rd November 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Thurn Court is a residential care home run and owned by Adult and Housing Department, and is located in the residential area of Thurnby Lodge. The closest shopping area is on the Humberstone Road, where residents have access to shops, the post office and other amenities. Public transport is close to the home and car parking is available to the front. Thurn Court is registered to accommodate up to 38 residents under the categories of older people and elderly residents, with dementia, mental disorder, physical disability and sensory impairment. There are 38 single bedrooms without en-suite facilities. Thurn Court consists of two floors with level entry access, with the first floor accessible by use of the passenger lift or stairs. Residents have a choice of lounges and seating areas. All the bedrooms are close to toilets, bathing and washing facilities. The home has a garden to the front and rear of the building which is well maintained and which is accessible to all the people living at Thurn Court. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 5 The maximum weekly fee is £359, information received before the inspection and confirmed on the day. There are additional individual expenditure such as hairdresser, chiropodist, newspapers, magazines and personal toiletries and the fee will depend on the services received. Information about the Thurn Court is located at the main entrance detailing the range of services offered, which includes the Statement of Purpose. A copy of the latest Commission for Social Care Inspection reports (CSCI), inspection report is located in the foyer with the displayed registration certificate. The residents are informed of the findings of the CSCI inspection at the ‘Residents Meetings’ or individually. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspected the Thurn Court using the method ‘Inspecting For Better Lives’, which is based on outcomes for the residents. The inspection process consisted of pre-planning the inspection, reviewing the last inspection report and the reviewing of the Pre-Inspection Questionnaire and Comment Cards/Surveys distributed to residents and General Practitioners by the CSCI along with the reviewing of significant events. Eighteen Comment Cards were sent out to residents, and General Practitioners. The unannounced site visit commenced on the 21st December 2006 and lasted 1 day. The method of inspection was ‘case tracking’. This involved identifying residents with varying levels of care needs and looking at how these are being met by the staff at Thurn Court. Six residents were selected and discussions were held with five residents and the relative of a resident to ascertain their views about the care provided. Residents individual care records were reviewed; discussions with care staff with varying responsibilities within the home and reviewing the health and safety records, training records and the minutes of residents and team meetings. Comments received from the General Practitioners indicated that they are well informed; staff demonstrated a clear understanding of care needs of residents, managed medication appropriately and had no complaints. Overall, the General Practitioners were satisfied with the care provided to the residents in the home. There were 44 of Comment Cards received from the residents, of which some were completed with the assistance from their relatives. The majority of the comments received were complimentary about the care received and the staff. Comments incorporated within Service User Comment Cards included: “Nephew assisted with the paperwork and choosing the home”. “Lived local beforehand and requested to live at Thurn Court”. “Satisfied with all care and support”. “Would like to be offered a bath more often. Staff always wash my back but I wash everywhere else, which is sometimes an effort”. “Prompt when using call bell system”. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 7 “If staff notice that I am unwell health care will be arranged and I get to see someone if I tell them I’m not well”. “Will be offered to participate but I am not interested and don’t attend” “Usually wishes to watch TV and not participate in activities”. “Dislikes vegetables apart from cauliflower and broccoli. Would like some staff to ask before serving other vegetables onto my plate”. “Will always speak with officer on duty”. “I know to speak with officer on duty or manager. Don’t recall being told about official complaints”. “Staff attend daily to make sure things are kept clean and tidy” “Very clean. Staff will say when bedroom carpet is cleaned so that I can sit in the lounge because the floor is slippy”. “The home is always spotless. It couldn’t be cleaner – 10/10”. “When I came in Thurn Court, I was most unhappy to have to leave my little house. But now after 5 months and a lot of TLC I can say this is now my home and I’m, very happy”. What the service does well: Residents live in a well maintained home that is clean and homely. The atmosphere in the home is relaxed and welcoming. Visitors are welcome at the home at any time and meet in private. Residents are involved in the planning of the care to meet their individual care needs. All the residents have a named care staff known as a ‘key worker’ who is responsible for making sure all aspects of their care, living arrangements are accommodated and personal toiletries are available. Residents have the opportunity to take part in various activities organised within the home. Residents receive a variety of good meals including special diets. Residents’ benefit from a stable group of staff that are well trained, of which, 52 having attained a National Vocational Qualification in Care. Staff demonstrating good awareness of the resident’s routines and preferences they care for. Staff have access to a variety of health and safety training, as well as training involving specific types of care such as dementia and stroke awareness. Information is well displayed for the residents and visitors to the home, such as the staff on duty, complaints procedure, contact details of Advocacy Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 8 services and planned social and leisure activities. The home is well managed by the management team who have specific areas of responsibility. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 9 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 Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents care needs are well assessed before they move into the home to ensure their needs can be met. EVIDENCE: Since the last inspection, the statement of purpose was revised to reflect the changes in the Leicester City Council and known as Adult and Community Services Department. The document is being revised to reflect the change of the departmental name following the merger of two departments. The document has information about the aims and objectives of Thurn Court, type of care provided, the experience and training of the management team and staff, key policies and procedures and the complaints procedure. The information is in an easy to read style. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 11 The admission procedure viewed for six residents tracked, including married couple, new residents, of which one was a planned admission and the other an emergency admission. All care files contained a copy of the social worker’s assessment of needs undertaken as part of the referral process. The assessment form has written information about the residents care needs, history such as medication, mobility, special or cultural diets and meals, communication needs, mental wellbeing and social, religious and cultural needs and needs of a married couple. The assessments included details of any health care needs provided by the District Nurse. Residents said they or their relatives were involved in choosing Thurn Court and the admission process to ensure their needs would be met. The new residents said that their family visited the home to see if Thurn Court would be suitable. The resident admitted to Thurn Court in an emergency said they and their relatives were fully informed before and during the admission process about the home and the provision of care. Staff said they were informed of new residents and significant events affecting residents at the handover meetings, which the Inspector observed. The home does not provide intermediate care. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well cared for having their tailored health and daily care needs met in a way that promotes and supports their lifestyle. EVIDENCE: The care plans and records of six residents, which included a married couple and new residents, were viewed. The care plans were generally well written in the context of the resident’s ability. Residents said they were involved in developing the care plans and how their needs are met. The care plan developed by the social worker was used for the resident admitted in an emergency, in the first instance. The care plans were personal to the resident, setting out the level of assistance required and any impairment such as poor hearing or sight. Care plans detailed information as to residents’ health care needs, daily living arrangements, which outline residents, preferred daily routine and the impact of cognitive Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 13 skills such as dementia, on the individual. Care plans gave information in relation to identified risks and how these should be minimised. Care records showed the key workers carried out a review of care needs with the residents on a monthly basis, which is recorded. Discussion took place with the senior and Registered Manager regarding care plan review notes, to be reflective views of the resident, if they are involved. This supported the discussion with the Team Manager and evidence from the monthly visits reports highlighting the need to improve care planning and reviewing, to be more centred on the resident. All the care files viewed contained good evidence of the involvement of General Practitioners (GP), District Nurses, Chiropodists and Optician and details of any treatment and instructions for care staff to follow. Discussion with the staff indicated that there was good communication between the home and the District Nurses. Residents said that they have seen their GP when requested or in an emergency. One resident said the District Nurse visits every Friday to dress her legs and this was reflected in the care notes. Comment cards received from GP’s all felt residents are well care for; staff are available; know the residents and do follow instructions. Residents were able to describe how care staff support them with daily tasks such as bathing and choosing their clothes. All residents have a named care staff known, as a ‘key worker’ to support their needs, daily routines, help keep their bedroom and clothes tidy. Observations made during the inspection showed care staff are vigilant to needs, interacting with residents and responding to call bells promptly. The Inspector saw residents being assisted to their bedroom or to the toilet when requested and responding to call bells promptly. Care staff were seen addressing residents by their preferred names, being near to residents when speaking with them and walking with residents at their pace. A new medication cabinet is now in use and stored securely in the treatment room. Residents said they received their medication on time. Trained senior carers and the Assistant Manager administer medication. At lunchtime, the senior carer was seen giving medication to residents individually and completing each record. The medication checked against the medication records for three residents tracked and other resident, indicated medication and records were correct and up to date. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents continue to make choices about daily living and are offered a variety of meals and social and cultural activities of interests. EVIDENCE: The residents have a choice of lounges on the ground and first floor, which includes a smoking lounge. Residents were seen receiving visitors throughout the day. Several residents said they receive their daily newspaper and enjoy reading books in the lounge with the large selection of books in large print. The daily records and the ‘Activities Book’ showed to which residents have participated in, include bingo, hairdresser, quiz nights, film nights dominoes and ball games. There is no ‘Activities Organiser’ but care staff amongst themselves, organise the activities with the residents. Information received before the inspection indicated that residents are offered a range of social, leisure and cultural activities of interests. The notice board in the main entrance listed these events for the week, including visits by the Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 15 hairdresser. Church services are held monthly basis, including representatives from Methodist church. Residents said they were not restricted and could meet with their relatives and friends in private. One resident expressed happiness to be living near her family, friends from the church and the minister, who visit regularly. All the residents commented on the Christmas Party held the previous evening, which was entertaining and obviously enjoyed by all the residents. Residents said their families were welcome; there was selection of food, drinks and sherry. The care plans viewed contained background information as to resident’s hobbies, interests, likes and dislikes and the involvement from family and friends from the church. Residents’ specific cultural needs and special diets such as diabetic or soft meals were detailed and known to the staff. Residents were aware of their right to look at their care file at any time. Daily records showed residents made choices, examples of which included whether they participate in social events such as Bingo, where they wished to eat their meals and whether to have a bath or shower. Residents’ said care staff were very helpful and supported them to make daily choices and maintain their abilities such as choosing how they spend the day to what time they go to bed. Care staff were aware of residents preferences and routines. Residents’ described how care staff helps them maintain their independence, and comments received: “Carer’s help with personal care, will remind me if I forget” “It’s really nice that they cover you up so that your bits can’t been seen” “Carers . . . all staff always speak with you not tell you” All residents spoken with said how much they enjoy the food. Meals were observed being served at the dining tables, with residents helping themselves to the vegetables. The majority of residents enjoyed a choice of corn beef hash or sausage and onions with vegetables and a choice of deserts. The Inspector observed how residents were supported to maintain their own independence by having specially adapted cutlery and plate guards. A care staff was observed assisting a resident with their meal, in a discreet and dignified manner. Residents were heard being offered a choice of both main course and dessert. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust and accessible complaints procedure and by staff trained in safeguarding adult processes. EVIDENCE: Residents and their relatives said they were informed of how to complain when they first visit the home. Details of how to complain are displayed on the notice board near the entrance to the home, by the public telephone and on the notice boards near the lounges. The complaints procedure is available in other languages, symbols and formats. Advocacy Services contact details are listed with the complaints procedure. Residents said they felt confident to complain directly or through their relatives, staff on duty or the managers. The new residents said they were are asked frequently if they are satisfied with the care provided. The complaints log showed no complaints were received by the home and no expressions of concerns were expressed to Commission for Social Care Inspection regarding Thurn Court. Care staff and seniors spoken with had a good understanding of their responsibility and procedures to follow in relation to safeguarding adults and were confident to whistle blow on poor or bad care practices. Staff files seen Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 17 contained evidence to show that staff have received training in safe guarding adults initially through the local authority programme of induction training, and as part of attaining a National Vocational Qualification (NVQ) in care. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ generally benefit from having a clean, safe and maintained accommodation, which individually and collectively meets the residents’ needs. EVIDENCE: Thurn Court is well maintained, decorated and furnished to a good standard, providing a comfortable and homely environment. The corridors throughout the home are brightly lit with handrails to help residents. The garden and the surrounding areas near the home are well maintained. The environmental improvements made since the last inspection includes re-decoration of the bathrooms and toilets and corridors and externally re-pointing of brickwork and painting. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 19 Residents and visitors all commented on particular care staff who had put up the Christmas decorations. All the lounges were decorated individually with soft Christmas music playing. Thurn Court benefits from a number of lounges of different sizes on the ground and first floor, a lounge with dining area and the main dining room on the ground floor. A small lounge on the ground floor designated as a ‘smoking lounge’ for those residents wishing to smoke. The Inspector observed residents moving around the home, choosing to sit in their preferred lounges or going to their bedroom. Residents were seen using the passenger lift independently and walking using their walking aids. One resident commented on preferring to sit in the upstairs lounge with the library, where it was quiet. The Inspector viewed four resident’s bedrooms (with consent), which were clean and homely, created by personal affects, furnishings and pictures. Residents felt they had sufficient private space for their personal belongings and to store walking aids. Bathrooms and toilets were clean and equipped with specialist equipment for the moving and handling of residents and a supply of protective clothing such as gloves and aprons. The laundry room is away from the kitchen with a team domestic staff responsible for cleaning and residents’ laundry. Staff described the arrangement for collecting residents’ laundry and the procedures followed for soiled clothes when handling clothing to avoid spreading infection such as MRSA. Care staff were seen wearing protective clothing when handling food and assisting resident to the bathroom. Care staff spoken with demonstrated a good understanding and knowledge of their responsibilities to prevent the spread of infection and health and safety guidelines. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trained and qualified staff are employed following thorough recruitment checks and employed in sufficient numbers, with the use of agency staff to meet the needs of the residents. EVIDENCE: On the day of the inspection, the care and ancillary staff on duty was as per the staff rota. The home continues to use agency care staff to make up a full compliment of care staff. The senior carer said the agency staff are regular and familiar to the residents and the procedures in the home. Care staff spoken with felt whilst agency care staff assist with residents and the daily tasks in the home, the home would benefit from having permanent staff. The local authority’s recruitment procedure is robust, which is managed by the Human Resource Team. The information received from the Registered Manager before the inspection showed staff have satisfactory pre-employment checks including Criminal Records Bureau (CRB) and references. The Inspector discussed with the Registered Manager and the Team Manager the need to demonstrate that pre-employment checks are carried out for the staff employed. The Team Manager acknowledged this and gave assurance that arrangements would be made to demonstrate checks are in place. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 21 Care staff spoken with described the recruitment process, which was consistent with the local authority recruitment procedure and the induction training received. The Inspector examined four care staff’s file, which contained confirmation of the completed induction training and job specific training. All but one staff file had records of the supervision meetings, which was confirmed by the care staff. Minutes of the staff meetings are produced timely and available to staff unable to attend. The information received from Thurn Court before the inspection indicated that 52 of the care staff had achieved National Vocational Qualification (NVQ) level 2 in care, with a further 23 of care staff care in the process of completing NVQ 2 in care and 64 of care staff hold a current first aid certificate. Staff training records showed training completed in moving and handling, safe guarding adults, food hygiene, fire training, infection control training, COSHH (Control of Substances Hazardous to Health) dementia awareness, person centred care, stroke awareness, older people and mental health. Care staff demonstrated a good awareness of the residents’ care needs, how to support and assist residents to maintain and continue living independently, as far as practicable. The residents and their visiting relatives said the care staff are always available and residents were familiar with them. Comments received included; “Always made to feel welcome” “They do know . . . . quite well and are sensitive to her needs” Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager offers a sense of leadership, ensuring residents health; safety and welfare are promoted and protected by the home’s procedures. EVIDENCE: The Registered Manager has clear lines of responsibility and accountability for all the staff at the home, and is supported by the Assistant Manager. Staff said they understood their role and worked as a team, with responsibilities such as assisting in the dining rooms, assisting residents with personal care, attending appointments and supporting the District Nurse. Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 23 The Team Manager, directly manages the Registered Manager, does the monthly visits to the home, generating a report of the findings, to represent the Responsible Individual, was visiting. The Team Manager confirmed work is continuing to look at improving the care planning for residents, as indicated in the previous monthly visit report. Quality Assurance was discussed with the Registered Manager and the Team Manager and it was acknowledged that there is no formal quality assurance exercise carried out that looks at the quality of the service against the home’s aims and objectives set out in the Statement of Purpose. The Team Manager spoke about the monitoring that does take place and accepted there was no evidence of the findings gathered to measure the quality of provision provided to people living at Thurn Court. ‘Residents’ meetings’ are held every three-months and residents can choose to attend. The minutes of the meeting viewed showed the topics discussed at the last meeting meals and plans for Christmas festivities. Some residents said they like to be involved when planning changes or social events in the home. Residents said they have keys lockable cabinet and to their bedrooms. One new resident said the lock was faulty on the cabinet and would have to wait for a new lock. This was brought to the attention of the Registered Manager and Team Manager, who confirmed a new lock was ordered and gave assurance that an alternative storage would be provided in the interim. Care plans viewed showed how the resident manages resident’s finances, independently or supported by their family. Residents described the process of getting their money, signing records that are overseen by the Administrator. Resident’s relatives were confident that the residents’ money was well managed and records maintained to show the balance at any time. This demonstrated there is a clear procedure for handling money was in place. The Registered Manager stated that supervision of staff does take place. Senior care staff said they receive supervision from the line manager and conduct supervision meetings with care staff they manage. However, a care staff said they had not received supervision since being appointed over two years ago. This was shared with the Registered Manager and unable to confirm whether all staff received timely supervision but said he would be followed-up. Risk assessments carried out with residents for mobility, falls, dietary needs and the measures were reflected the their care plans used by staff. Residents said they felt safe both in the home and with the care staff looking after them. The Pre Inspection Questionnaire received by CSCI before the site visit detailed the regular maintenance of health and safety systems in the home such as equipment, fire, central heating and emergency call bell systems. Records randomly checked indicated fire drills and alarm tests are carried out regularly. The accident book was consisted with the notifications sent to the CSCI detailing events that have affected the residents’ safety and wellbeing. Thurncourt DS0000036629.V323435.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 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X X X 3 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 3 X 3 Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. Refer to Standard Good Practice Recommendations Thurncourt DS0000036629.V323435.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Thurncourt DS0000036629.V323435.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. Re-publishing this information is in breach of the terms of use of that website. 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