Inspection on 09/11/05 for Thurnscoe Hall Nursing Home

This inspection was carried out on 9th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Thurnscoe Hall Nursing Home 16/11/07

Thurnscoe Hall Nursing Home 03/04/07

Thurnscoe Hall Nursing Home 25/04/06

Thurnscoe Hall Nursing Home 03/05/05

Thurnscoe Hall Nursing Home 12/10/04

Thurnscoe Hall Nursing Home 04/06/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Thurnscoe Hall Nursing Home High Street Thurnscoe Rotherham South Yorkshire S63 0ST Lead Inspector Mr Steven Vessey Unannounced Inspection 9th November 2005 11:35 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 Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 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. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thurnscoe Hall Nursing Home Address High Street Thurnscoe Rotherham South Yorkshire S63 0ST 01709 890086 01709 894363 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) www.thurnscoehall.co.uk Mr Rajendra Prasad Vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 26 beds, 12 are nursing care (N) and 14 are personal care (PC) Persons accommodated shall be aged 55 years and above Date of last inspection 3rd May 2005 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 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. Accommodation 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 DS0000006492.V261468.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There had been a complaint made to the Commission for Social Care Inspection relating to the home. There were five elements to the complaint and the provider was asked to investigate. One element of the complaint was upheld, three elements were not upheld and one element was unresolved. This unannounced inspection took place over approximately five hours from 11:40 to 16:50. The inspection process included a partial inspection of the premises, inspection of a sample of records and policies, discussions with staff, residents and relatives 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 six staff, five residents and relatives in some detail. What the service does well: What has improved since the last inspection? The written terms and conditions in residents’ files included information relating to the fees payable. Residents spoken to were happy with the food provided and there had been some improvement in the choices available at teatime. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 Page 6 Some maintenance work had been carried out, including the redecoration of some bedrooms, the repair of some communal carpets to reduce the tripping hazard for residents and the replacement of some bedroom carpets. A new refrigerator and water boiler had been purchased for the main kitchen and a dryer had been replaced in the laundry. Some new chairs had been replaced in the communal lounge and some new lighting for the lounge had been purchased and is to be installed in the near future to improve the comfort in the communal lounge. Staff had attended adult protection training, improving the level of protection for residents. The management of resident’s money had improved, two signatures were now included on records to witness any money put in or taken out of the safe on behalf of residents. The level of health safety and welfare of residents had increased as the work following recommendations from the fire officer had been done, a system for the checking and recording of water temperatures had been put in place and there had been an improvement in the information included on accident records. 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 DS0000006492.V261468.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 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 the following standard(s): 2, Standard 6 not applicable at the home. Residents had a written contract/statement of terms and conditions with the home. EVIDENCE: Two residents’ files included a copy of the written contact, which included the fees charged. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 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 the following standard(s): 9 and 10 Medication was stored securely and managed well. Residents felt that they were treated with respect and that they had adequate privacy. EVIDENCE: Records were kept of medication being received into and leaving the home and appropriate arrangements had been made for the disposal of the medication of residents receiving nursing care. Medication administration records were fully completed. Qualified nursing staff administer medication and medication, including controlled drugs, was stored appropriately and securely, maintaining the heath safety and welfare of residents. Residents spoken to stated that they were well cared for, staff treat them with respect and they were able to spend time in their room if they wish. Care staff were able to describe how they promoted privacy and dignity when providing care for residents and nursing staff described how they monitored care delivery to ensure the privacy and dignity of residents was maintained. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 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 the following standard(s): 15 Residents and relatives were satisfied with the quality and quantity of food provided. EVIDENCE: Residents and relatives were in the main positive about the food; residents stated that they were given the choice of a cooked breakfast everyday and residents spoken to stated that they had enjoyed lunch. Residents stated that they usually had assorted sandwiches and cakes for tea but that soup and a hot snack was also offered at teatime and they could have a sandwich, bun or biscuits for supper. However some staff felt that the residents would benefit from improved menus at teatime. The manager stated that the catering team had recently been reassessed and awarded a silver award for catering by the local authority and has been recommended by the dietician for the gold award. Catering staff had all undertaken the intermediate food hygiene training and all other staff had received food handling training. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Residents were aware of how to complain and thought that their complaints would be listened to and dealt with. Recorded complaints had been investigated and attempts had been made to resolve them. In the main residents were protected from abuse, the level of protection could be improved if adult protection policies and procedures from other relevant local authorities were available. EVIDENCE: Residents spoken to stated that they would speak to the manager if they had any complaints and stated that they thought any complaints would be sorted out. The complaints log included detailed records of two recent complaints, one of which had been made to the Commission for Social Care Inspection, investigations had taken place and attempts had been made by the manager and the owner to resolve the complaints. A copy of the Barnsley local authority adult protection policies and procedures were available to staff and staff had received adult protection training. Residents funded by other local authorities were living at the home; the adult protection policies and procedures for these local authorities were not available. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 24 and 26 Some areas of the home had been redecorated, however the main kitchen was still in need of upgrading, the conservatory roof, the damage to the wall in doorway to the conservatory and the ceiling on the second floor needed repairing and redecoration. Residents were happy and comfortable in their rooms, however the ceiling in the bedroom that had sustained water damage from a leaking pipe needed repairing and redecoration. The home was in the main clean, pleasant and hygienic and residents were satisfied with the laundry service. EVIDENCE: The reception area and three bedrooms had been redecorated and some bedroom carpets had been replaced, improving the living environment for residents. A new refrigerator and water boiler for the main kitchen and a new dryer had recently been purchased. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 Page 13 Communal carpets in the conservatory and on the second floor corridor had been repaired, reducing the tripping hazard for residents and staff. Some lounge chairs had been replaced and new lighting had been purchased for the communal lounge, which was to be installed in the near future, improving the comfort for residents. The plastic covering on the handrail on the stairs was becoming detached from the handrail. The bedrooms checked were in the main well decorated, however one bedroom ceiling had sustained some damage from a leaking pipe. Residents stated that they were happy and comfortable in their bedrooms and that they had everything they needed. The manager stated that some work had been done on the conservatory roof, but that this had not prevented the roof from leaking. There had been some damage to the wall by the door of the conservatory, which had exposed a metal strip that was a risk to the health safety and welfare of residents and staff. The ceiling on the second floor had sustained some damage from a leaking roof or gutter and was in need of repair and redecoration. Residents stated that the home was always kept clean and that there were never any unpleasant odours, they were also happy with the laundry service stating that their clothes were returned quickly and that clothing was not lost or damaged during the laundering process. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 Sufficient staff with an appropriate mix of skills was on duty to meet the needs of the residents. The majority of the care staff are NVQ level 2 trained and the remaining staff are currently undertaking the NVQ level 2 training. Staff had received some induction training and had opportunities for further training; the evidence of staff training would be more robust if training records were kept up to date. EVIDENCE: The deputy manager was on duty as the nurse in charge, there were also two care assistants, the cook, one member of staff working in the laundry and two members of cleaning staff working around the home. Some staff and residents felt that there was enough staff to meet the needs of the current number of residents, whilst other staff and residents thought that more staff would enable staff to spend more time with residents. However staff stated that residents care needs were met to a high standard, residents stated that their needs were met, staff were always available to offer assistance and if they were in their room and used the call buzzer staff came quickly to assist them. The manager stated that there were two care staff currently undertaking the NVQ level 2 in care and that all other care staff were trained to at least NVQ level 2. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 Page 15 Staff stated that they had received some induction training and that they were given opportunities for other training, which had included, NVQ level 3, first aid, moving and handling, and health and safety. Staff stated that the manager was very supportive in relation to training and that if they identified a training need the manager would endeavour to provide the training. Training records identified that some staff were in need of moving and handling update training. The manager stated that some staff had recently received an update to their training but that this had not yet been recorded. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 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 stated that they were asked their thoughts about the home, however the quality monitoring process would be improved if the owner completed a monthly report following his visits to the home and forwarded this to the Commission for Social Care Inspection. The certificate of insurance on display was out of date. Residents’ financial interests were safeguarded. Residents felt that the home was safe, the health safety and welfare of residents and staff would be more fully protected if all the fire doors closed when the fire alarm was activated. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 Page 17 EVIDENCE: The manager is a nurse with extensive management experience and had been a registered manager in the past, however she is not currently registered with the Commission for Social Care Inspection. Some residents stated that the manager spends time talking to them about the home and staff stated that they are involved in discussions about the home at staff meetings. Staff stated that the owner visits the home several times each week and speaks to residents and staff when he visits, there were some records relating to the owners visits, however these were incomplete. The manager stated that she had arranged meetings in an attempt to involve residents and relatives in a more formal consultation process but attendance had been poor. Relative and resident feedback forms were available in the foyer to enable feedback to be given. The insurance certificate on display in the reception area showed that the insurance cover had expired. The manager stated that the insurance company were visiting in the near future to carry out an inspection of the premises. Staff were aware of the procedure for handling residents money, written records were kept of all transactions, which included two signatures, three residents money was reconciled with the records. Residents and relatives spoken to stated that they felt that the home was safe. A system for the monitoring and recording of water temperatures had been implemented and hot water temperatures checked were around 43 degrees centigrade. Accident records were fully completed. The manager stated that the recommendations following the last fire officers visit had been implemented, however she stated that one set of fire doors on the ground floor were closing properly when the fire alarm was activated. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 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. Standard OP19 Regulation 23 Requirement 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 (Previous timescale of 03/07/05 not met). The damage to the wall in the entrance to the conservatory must be repaired. The leak in the roof or guttering must be repaired. The handrail on the staircase must be repaired. The ceiling on the second floor must be repaired and redecorated. The ceiling in the identified bedroom, which had sustained water damage, must be repaired and redecorated. Up to date training records must be kept for all staff. Timescale for action 09/02/06 2. 3. 4. 5. 6. 7. OP19 OP19 OP19 OP19 OP19 OP24 23 23 23 23 23 23 09/01/06 09/12/05 09/01/06 09/02/06 09/01/06 09/01/06 8. 9. OP30 OP31 19, Schedule 4 9 09/01/06 The manager of the home must 09/03/06 be registered (Previous timescale of 04/01/05 not met). Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 Page 20 10. OP33 26 11 OP35 25 12. OP38 23 A written report of the owner’s monthly visit must be completed and forwarded to the Commission for Social Care Inspection (CSCI). A valid certificate of insurance must be obtained and a copy forwarded to the CSCI local office. Appropriate action must be taken to ensure that the identified fire doors close fully when the fire alarm is activated. 09/12/05 09/12/05 09/12/05 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. Refer to Standard OP18 Good Practice Recommendations Adult protection policies and procedures should be obtained from other relevant local authorities. Thurnscoe Hall Nursing Home DS0000006492.V261468.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sheffield Area Office 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 DS0000006492.V261468.R01.S.doc Version 5.0 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. 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