Inspection on 12/06/07 for Thyra Grove Care Home

This inspection was carried out on 12th June 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thyra Grove Care Home 22/06/06

Thyra Grove Care Home 27/01/06

Thyra Grove Care Home 11/03/05

Thyra Grove Care Home 27/07/04

Thyra Grove Care Home 18/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Thyra Grove Care Home 11 Thyra Grove Mapperley Nottingham NG3 5GY Lead Inspector Rehana Rashid Key Unannounced Inspection 12th June 2007 10:45 Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Thyra Grove Care Home DS0000002257.V342953.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thyra Grove Care Home Address 11 Thyra Grove Mapperley Nottingham NG3 5GY 0115 955 5216 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) violet.priest@ncha.org.uk www.ncha.org.uk NCHA Miss Jennifer Norma Foran Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2006 Brief Description of the Service: Thyra Grove is an adapted Victorian property situated in a quiet cul de sac just off Woodborough Road. The accommodation is registered for up to four people who have a learning disability. The accommodation is over three floors and as there is no lift, service users would need to be independently mobile to live there. It is not accessible for people who use wheelchairs or who have mobility problems. All of the bedrooms are single, and one is on the ground floor. There are shops, churches and bus stops into the city, nearby on Woodborough Road. Information about the service is provided through the service user guide and statement of purpose. Copy of the most recent inspection report from the Commission for Social Care Inspection is available at the home. On 12 June 2007 the Registered Manager stated that the current weekly fee range is between £332 to £343. There are additional charges for transport for leisure trips. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which was conducted on 12 June 2007. The inspection took place over approximately five hours. The main method of inspection was case tracking, which involved selecting two residents and examining their care records. Case tracking is used to establish if the needs of the residents are being appropriately assessed by the home and their needs are being catered for. Indirect and direct observation of practice and interaction between staff and residents was also carried out as part of the inspection methodology. A partial tour of the building was carried out. Documentation including health and safety records were also examined. Two members of staff were spoken with. Due to the limited communication of the residents the inspector observed interaction between staff and the resident who was at home during the inspection. Prior to the inspection a pre-inspection questionnaire was sent out to Thyra Grove, which asked questions around the service including staffing levels and number of service users. The pre-inspection questionnaire, which was returned to the Commission for Social by the registered manager, was used within this inspection report Surveys were sent out to service users and their relative’s representatives and advocates to gain their views about the service received. One completed survey from a service users was received; one survey was received back from service users relatives, representatives and advocates. On the day of the inspection there were four residents in residence. The registered manager supplied much of the information provided for the inspection. What the service does well: Residents support plans and risk assessments were detailed clearly documenting resident’s individual needs and how these are to be met. Specialist health and social care services are accessed when required to assist or provide further support for residents. Staff spoken with demonstrated a good understanding of the needs of the residents. Residents are provided with varied and individualised social activities both within the home and in the community. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 6 A comment written in a survey from a relative stated “we are very pleased with the very high standard of care received by our relative.” Thyra Grove Care Home provides its residents with a clean and homely environment. 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. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have suitable information to make an informed choice about where to live. Their needs are assessed prior to moving to the home, ensuring that identified needs can be met. EVIDENCE: The statement of purpose contains all items as specified under schedule 1 of the Care Home Regulation 2001. Most of the residents at Thyra Grove Care Home have been placed there for several years. Since the last inspection there has been one new admission. The residents care files were viewed, which contained comprehensive preadmissions assessments. These included community care assessment and risk assessment from the placing local authority. Prior to the resident moving to Thyra Grove, there have been meetings with other professionals including Social Worker to ensure the placement is suitable and it goes smoothly. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good arrangements in place ensuring that individuals’ needs and choices are met and that residents can participate in their chosen activities safely. EVIDENCE: Support plans were viewed for two residents, these were very detailed and individualised. The support plans covered all aspects of personal and health care needs. The support plans and risk assessments have been reviewed at regular intervals and updated if there has been a change in the residents needs. Members of staff spoken with stated if there has been a change in a residents needs, this information is shared with them immediately so that they are kept up to date with any changes. One staff member stated communication between the staff team is very going. The support plans make reference to residents’ personal preferences and how individual residents are enabled to make decisions about their lives. Staff were observed communicating with residents effectively and in a respectful manner. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 10 Risk assessments were in place where a particular risk has been identified which included individual behaviour and risk of going out unsupervised. The risk assessment clearly detailed action required to minimise the identified risk. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of suitable activitives are provided, which meet the leisure and recreational interests of residents. EVIDENCE: During the inspection two residents were attending day care, whilst one resident was at home and another resident was away on holiday with staff. The resident who is supported at home by an worker from an external agency that visit Thyra Grove Care Home, ensuring that the resident receives suitable social stimulation. Photographic display evidenced that residents participate in social activities. Resident’s activities folders showed that social activities are planned according to individual choice and interests. Social activities for residents included going to the cinema, local pub, parks, holidays and swimming. One resident’s file showed that they had gone to Spain on a holiday with staff. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 12 Comments in a residents survey included that there are lots of activities to do and always given a choice. Resident’s care files viewed showed that their care plans reflected residents individual social needs. These also evidenced that residents were supported to maintain contact with family and friends. The inspector observed positive interaction between staff and residents. Staff interacted with the resident in a respectful and caring manner. Staff spoken with discussed how they ensure residents privacy and dignity is maintained. The menu is planned in consultation with residents, using pictures. The deputy manager stated that the menu is changed according to the season. Food storage and preparation areas were clean and organised. Records are kept of alternative meals provided and food-probing temperatures are recorded. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ healthcare needs are well met and they receive personal support in the way they prefer and require. Medication management has improved ensuring the safety of the residents. EVIDENCE: Two resident’s files viewed at this inspection contained comprehensive details of their personal and health care needs. Daily communications sheets and care plans confirmed residents receive input from specialist health and social care professionals including GP, Social Worker and Psychologists. Staff spoken with were aware of individual health care needs and preferences. Healthcare appointments are documented, which shows that residents have access to chiropody, dentist and to the GP. Medication management has improved since the last inspection. Medication was observed to be stored securely in a lockable cupboard. Thyra Grove Care Home uses a monitored dosage system for the majority of the medicines. Medication is stored in a lockable cupboard. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 14 The Medical Administration Records (MAR) were found to be well organised in the file and there was no gaps in the entries for the two residents case tracked. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a complaints system in place. Procedures must be improved to fully safeguard residents at Thyra Grove Care Home. EVIDENCE: The complaints procedure and complaints record, which is computerised, were viewed. The complaints procedure was also available in a pictorial format, displayed in the home. The registered manager stated that since the last inspection one complaint had been received. The investigation concluded that the complaint was partially substantiated. Two surveys returned from a resident and a relative stated that they are aware of the complaints procedure. One staff members training records viewed showed that they had not received training in safeguarding adults. During a discussion with a staff member they stated that they had not received training in safe guarding adults. All staff employed by the home must receive training or refresher training in safeguarding adults this will ensure residents are safeguarded from all forms of abuse. The registered manager stated that since the last key inspection there have been no safeguarding adults investigations or allegations. Two staff members spoken with were able to discuss the actions they would take if an allegation of abuse was made and they were clear about their responsibility to report the allegation. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 16 Financial records for two residents were examined and found to be satisfactory. Receipts are kept to show transactions. Individual records are held for each resident providing detail of expenditure and balance. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thyra Grove Care Home provides the residents with a clean and comfortable environment. EVIDENCE: Thyra Grove Care Home provides its residents with a clean and homely environment. A partial tour of the building was given by the deputy manager. Communal areas including the kitchen, lounge and dinning room were well maintained and pleasantly decorated. The bathroom and shower room were clean and free from odour. The laundry facilities are appropriate for the needs of the current residents they include a washer and dryer. The communal areas of the premises viewed were clean and tidy. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are sufficient to meet the needs of the residents. Residents are supported by competent staff. EVIDENCE: The staff rota provided evidence that sufficient staff are on duty to meet the current needs of the four residents at Thyra Grove Care home. Staff spoken with stated that the current staffing levels are generally adequate. One staff member expressed that as all four residents are at home during the weekend, an additional member of staff on duty maybe beneficial. There are two staff on duty in the mornings, two in the afternoons and one waking in staff at night. Both staff members stated that the staff team at Thyra Grove Care Home are supportive and that the communication between staff is very good. At this inspection it was not possible to inspect recruitment policy and practices. There is an arrangement between the Commission for Social Care Inspection (CSCI) and Nottingham Community Housing Association (NCHA) that all staff personnel files are held at the central office for NCHA. It was agreed between CSCI and NCHA that details of staff records to be set out in an pro-forma or similar document capturing information such as pre employment checks including Criminal Bureau Records (CRB) and references and for this to Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 19 be kept at the home. Despite this agreement this system has not been implemented at Thyra Grove Care Home. When asked in the relatives survey if the care staff have the right skills and experience to look after the residents, the relative wrote “most certainly.” Training certificates were not seen at the inspection as they are held centrally. Staff spoken with reported that the training provided is relevant to the job and that the registered manager encourages staff to undertake training. The registered manager stated that over 50 of the staff team have attained National Vocational Qualification level two. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home. The health, welfare and safety of residents are promoted and protected. EVIDENCE: Thyra Grove Care Home manager is registered with the Commission for Social Care Inspection, she has achieved National Vocational Qualification Four. Staff stated that the manager is supportive and approachable. Files inspected were kept in good order and easily accessible for inspection. In accordance with Nottingham Community Housing Association Thyra Grove Care Home has three quality audits over the year. Minutes from the most recent residents meeting were viewed, the agenda was very user friendly produced in a pictorial format. Resident’s surveys should be available in a format more accessible for the residents. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 21 Some records relating to health and safety were examined. Gas servicing certificate was viewed and has been taken place at the required interval. Records including fire testing, which include emergency lighting, fire drills and fire alarm testing showed that these have been carried out. Fridge and freezer temperatures are monitored daily and recorded. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13.6 Requirement The registered person must ensure all staff receive training in safeguarding adults. Also for all staff to receive annual updates to ensure that they are aware of updates and best practice. This will ensure service users are safeguarded from all forms of abuse. The registered person must ensure that a record of when staff members commenced employment and there should be evidence in the care home that satisfactory pre employment checks have been obtained to include criminal record bureau check for all staff. This is to satisfy the Commission at the time of the inspection that this standard is being met and is in line with current CSCI guidance on criminal record bureau checks. This will ensure residents are safeguarded. Timescale for action 31/10/07 2. YA34 17, 19 01/08/07 Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 24 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 YA39 Good Practice Recommendations The registered person should ensure that resident’s surveys are available in appropriate formats, this will ensure that residents views on the service provided can be obtained. Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Thyra Grove Care Home DS0000002257.V342953.R01.S.doc Version 5.2 Page 26 - 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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