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Inspection on 03/05/05 for Thurnscoe Hall Nursing Home

Also see our care home review for Thurnscoe Hall Nursing Home for more information

This inspection was carried out on 3rd May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager is qualified, experienced and competent to manage the home. Residents were able to make choices about daily routines. Residents were pleased with the environment acknowledging in particular the standard of cleanliness within the home and that there rooms were comfortable. All areas within the home smelled pleasant and were cleaned to a high standard and the home had a pleasant atmosphere. Comments included "it`s a home from home" and " I wouldn`t want to go anywhere else". Residents receive a good standard of care, comments included "the carers are marvellous, they are a jolly good team". The residents said visitors could visit the home at any reasonable time. Residents were happy with the food provided at breakfast and dinnertime. Care plans contained all relevant information, were updated regularly and reviewed on a regular basis and there was a clear recruitment procedure in place for the protection of residents.

What has improved since the last inspection?

Some resident`s rooms have been redecorated and had new carpets; there is an ongoing plan of refurbishment for residents rooms until all rooms have been refurbished. Some minor work had been carried out in the main kitchen and some new equipment had been purchased. More training opportunities had been identified for staff.

What the care home could do better:

The manager needs to be registered with the Commission for Social Care Inspection. Work still needs to be carried out to upgrade the main kitchen and in other areas of the home including the replacement of some lounge furniture to improve the living environment. Improvements in the management of resident`s money would be achieved with the introduction of two signatures for written transactions made. Staff have training opportunities however more staff need to attend adult protection training. Residents stated that they would like more choice of food at teatime, a more formal consultation process would give them the opportunity to discuss this with staff. The home was, in the main safe, however to improve the level of safety a system should be introduced for the checking and recording of water temperatures, the recommendations from the fire officers report should be implemented, and accident records should be fully completed.

CARE HOMES FOR OLDER PEOPLE Thurnscoe Hall Nursing Home High Street Thurnscoe Rotherham S63 0ST Lead Inspector Steve Vessey Unannounced 03 May 2005 9:40 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. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Thurnscoe Hall Nursing Home Address High Street Thurnscoe Rotherham S63 0ST 01709 890086 01709 894363 None Mr Rajenda Prasad 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) Eileen Johnson (Awaiting Registration process) N - Care home with nursing 26 Category(ies) of OP - Old Age (26) registration, with number of places Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 55 years and above. Of the 26 beds, 12 are nursing care (N) and 14 are personal care (PC). Date of last inspection 12 October 2004 Brief Description of the Service: Thurnscoe Hall is a 17th Century stone built Grade 2 listed building with a purpose built extension and conservatory. It is situated in Thurnscoe village ten miles from Barnsley town centre, close to the A635 Barnsley to Doncaster road, with easy access by bus or train. The home is within walking distance of of all local amenities, including, supermarkets, chemist, optician, post office hairdressers, community centre, bowling green, pubs, clubs, the village church and health centre. The home stands in its own extensive gardens with mature trees and shrubs and has a sitting area for residents and their families. Accomodation is on three floors, served by a passenger lift. The home is registered for 26 residents with 12 nursing care places, for people over the age of 55 years. There is a car park to the side of the building. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately seven and a half hours from 9:40 to 17:15. The inspection process included a partial tour of the premises, inspection of a sample of records and policies, discussions with, the manager, staff and residents and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to five staff and four residents in detail. What the service does well: What has improved since the last inspection? Some resident’s rooms have been redecorated and had new carpets; there is an ongoing plan of refurbishment for residents rooms until all rooms have been refurbished. Some minor work had been carried out in the main kitchen and some new equipment had been purchased. More training opportunities had been identified for staff. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 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. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 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 Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 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) 2 and 3, standard 6 is not applicable at the home Residents had a contract, however this did not include the fees charged. Resident’s needs had been assessed prior to admission to the home. EVIDENCE: Four files included a copy of the contact, this did not include the fees charged. One out of four care plan files included a full needs assessment from the local authority. All four care plans files included a detailed assessment carried out by staff from the home. A detailed care plan was drawn up from the homes own assessment, including action for staff to take to meet the needs of residents. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 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, 8, and 9. Residents had a detailed up to date plan of care reflecting their identified assessed needs. Resident’s health care needs were met. Medication was managed safely. EVIDENCE: Four care plans included detailed information as to the actions required from staff to meet the needs of the individual residents and were reviewed regularly by staff. Residents seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved. Risk assessments were in place for, development of pressure areas, falls and nutrition, meeting the health care needs of residents. Residents stated that they were able to choose their own doctor. Records were kept of medication being received into and leaving the home. There were medication administration records for residents, which were fully completed Qualified nursing staff administer medication. All medication was stored appropriately and securely, maintaining the health safety and welfare of residents. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 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, 13, 14 and 15 Residents are given choice in many aspects of their lives, allowing them to maintain their independence. Residents were happy with the activities and outings on offer. Relatives and friends are encouraged to visit and participate in some aspects of resident care enhancing the quality of life for all concerned. Residents receive a choice of food, which is of good quality and can eat in a pleasant dining room or their room, residents were happy with breakfast and lunch but were unhappy with the choice of food for tea. EVIDENCE: Residents and staff stated that residents could choose when they get up and go to bed and could spend time in their room when they want to. Residents stated that if they did not like the food on the menu they could have an alternative, maintaining choice and independence. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 11 Residents were observed receiving visitors in communal areas of the home and stated that they could receive visitors in their room. Some residents stated that they did not go out of the home but that it was their choice not to, others stated that they sit out in the garden when it is nice and that they had been on trips in the summer. Staff stated that entertainment is provided on special occasions and that sometimes residents go out locally with their relatives or with staff. Staff stated that they do get time to spend with residents, but that it is sometime difficult to get residents interested in participating in activities. Some residents stated that they were able to manage their own financial affairs, other had family involvement, one resident stated that her money was in the safe and that she had used some of it to buy a television for her room. All residents spoken to stated that they were happy with the financial arrangements and that if they had money in the safe they could ask to see the records. Residents were generally positive about the food, comments included, “the food is good”, “we get good dinners, however they stated that sandwiches were offered for tea every night and that they would like other alternatives to be on offer. The manager stated that residents were given the choice of sandwiches or a hot snack and the majority of residents always chose sandwiches, the manager stated that one resident chose to have soup most evenings. Staff stated that when they commence work in the afternoon the speak to all residents and ask them what they want for tea, they stated that the choices include a hot snack and that residents had been offered sandwiches, soup or beans on toast on the day of the inspection. Some residents stated that they did not have supper, but that was because they chose to go to bed early, staff stated that hot drinks were served at suppertime with a choice of cakes, biscuits or sandwiches. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 12 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, 17 and 18 Residents were aware how to complain and thought that their complaints would be listened to and dealt with. Residents had the opportunity to register to vote. Policies and procedures are in place to protect residents from abuse, however staff need to attend adult protection training. EVIDENCE: Residents spoken to stated that they would speak to the manager or the deputy manager if they had anything to complain about and stated that they thought complaints would be listened to and sorted out. A detailed complaints log was available, there were no recent complaints recorded. Some residents spoken to stated that they had the opportunity to register for a postal vote in the forthcoming election. Policies and procedures were in place regarding recognising and reporting of abuse, some staff spoken to had attended abuse awareness training, other staff stated that training was planned and a notice was currently on display for them to attend training. The manager stated that all staff would have received training by September. A whistle blowing procedure was in place. Staff stated they would report any suspected abuse to the manager. A copy of the Barnsley local authority adult protection policies and procedures were available and accessible to staff. Residents spoken to stated that they felt safe. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 13 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, 20,24 and 26 Areas of the home accessible to residents were in the main well maintained, however the main kitchen is still in need of upgrading, the conservatory roof was leaking and two carpets in communal areas were a potential tripping hazard. The worn lounge chairs still need replacing. Residents were happy and comfortable in their rooms, however a carpet in one residents room was stained. The home was in the main clean, pleasant and hygienic. EVIDENCE: In the main the home was well decorated and well maintained, some residents rooms had been redecorated and had new carpets. The carpet in the conservatory was a tripping hazard it had become unsecured near the entrance and on where it had been joined, putting residents and staff at risk, and the carpet on the top floor corridor had been taped down. Residents stated that the leak in the conservatory roof was causing problems particularly in heavy rain. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 14 Staff stated that some tiles had been replaced in the main kitchen, however the requirement to carry out refurbishment of kitchen units and work tops had not been carried out. Staff stated that the comfort of residents could be improved with the provision of some new furniture in communal areas; the previous requirement to replace some worn lounge chairs had not been met. Residents stated that they were happy and comfortable in their rooms and that they were always kept clean however one bedroom carpet was badly stained. Residents stated that all areas of the home were kept clean and that they were happy with the standard of the laundry service. The laundry was sited appropriately and staff stated that there was sufficient equipment available within the laundry. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 15 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, 28, and 29 Sufficient staff with an appropriate mix of skills was on duty to meet the needs of residents. Some staff are NVQ level 2 qualified and others are currently undertaking NVQ level 2 qualification. A robust recruitment procedure was in place, protecting residents. Staff had received some induction training. EVIDENCE: The manager was on duty as the nurse in charge, there were also two care assistants, the administrator, two domestic staff, and a cook on duty. Staff spoken to stated that there was sufficient staff on duty to meet the needs of the residents. Some residents stated that they thought there could be more staff on duty, however residents stated that they were happy with the care that they receive. The manager stated that four care staff are qualified to NVQ level 2 and that three staff are currently working towards it. One member of staff spoken to stated that they had nearly completed the award. Three staff files contained CRB disclosures; files for staff that had been employed recently contained appropriate recruitment information. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 16 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) 31, 33, 35 and 38 The manager is experienced, qualified and competent to run the home, however she is not registered with the Commission for Social Care Inspection. Residents need to be consulted about the running of the home in a more formal way. A procedure on the handling of resident’s money was in place, however the introduction of two signatures for financial transactions on behalf of residents would safeguard their interests. Residents and relatives feel that the home is safe, however the testing of water temperatures should be introduced and recommendations from the fire officer’s report should be implemented, to improve the safety of the home. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 17 EVIDENCE: The manager is a first level nurse with extensive management experience working with the elderly and has been a registered manager in the past, however the manager is not currently registered with the Commission for Social Care Inspection. Residents and staff stated that the owner visits the home several times each week and speaks to them when he visits. The manager stated that the owner carries out regulation 26 visits and that he has the reports to forward to CSCI. Relative and service user feedback cards were left in the foyer to enable feedback to be given. The manager stated that new equipment had been bought and that there was an ongoing plan to redecorate and re carpet some bedrooms. A procedure for the handling of resident’s money was in place, this states that money is held in individual wallets and that the money is held securely. Written records of transactions were kept, however the financial interests of residents were not fully safeguarded as one person signs the majority of transactions. Records were in place stating fire equipment had been checked, regular fire drills take place and that staff have received fire training. Staff confirmed that they had received fire and moving and handling training, promoting resident safety. Fire records and the report following a visit form the fire officer identified that two fire doors were sticking, compromising the safety of residents. The manager stated that the gas appliances had been serviced and the electrical testing had been carried, however the certificates were not available. The manager stated that an automatic purifying system had been fitted to the water system, hot water temperatures checked were around 43 degrees centigrade, there was no record of water temperatures being tested, increasing the risk of scalding. The servicing of equipment had been carried out. Accident records were not fully completed, on one accident record there was no time or location of accident recorded. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 18 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 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 2 x x x 2 x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 2 x 2 x 2 x x 2 Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 19 Are there any outstanding requirements from the last inspection? Yes 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. 2. 3. 4. Standard 2 15 18 19 Regulation 5 16 13 23 Requirement The residents contract must include the fees payable. The choice of food on offer at tea time must be reviewed following consultation with residents. All staff must receive adult protection training A programme for the refurbishment of kitchen worktops and units must be provided (Previous timescale of 29/03/05 not met). The leak in the conservatory roof must be repaired. The identified communal carpets must be repaired or replaced The worn lounge chairs must be replaced (Previous timescale of 1/12/04 not met). The identified bedroom carpet must be cleaned or replaced The manager of the home must be registered (Previous timescale of 04/01/05 not met). Residents must be consulted in a more formal way and the results of the consultation must be published. Two signatures must be included on resident personal money accounts, wherever possible one J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Timescale for action 03/07/05 03/08/05 31/08/05 03/07/05 5. 6. 7. 8. 9. 10. 19 19 20 24 31 33 23 23 23 23 9 24 03/07/05 03/08/05 03/08/05 03/08/05 03/08/05 03/10/05 11. 35 16 03/08/05 Thurnscoe Hall Nursing Home Version 1.30 Page 20 of these must be the resident. 12. 13. 14. 38 38 38 23 23 23 The recommendations following the fire officers visit must be implemented A system must be in place for checking and recording water temperatures Accident records must be fully completed. 03/07/05 03/08/05 03/07/05 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. 2. Refer to Standard 28 Good Practice Recommendations 50 of all care staff should have NVQ level 2 or equivalent by 2005. Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thurnscoe Hall Nursing Home J51 S6492 Thurnscoe Hall V218840 03.05.05 UI Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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