Inspection on 22/06/06 for Thyra Grove Care Home

This inspection was carried out on 22nd June 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thyra Grove Care Home 12/06/07

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 Joanna Carrington Key Unannounced Inspection 22nd June 2006 10:00 Thyra Grove Care Home DS0000002257.V299888.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.V299888.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.V299888.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.V299888.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 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. The fees are £332 per week. Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over six hours on 22nd June 2006. This was the home’s key inspection for this financial / inspection year. The main method of inspection was called ‘case tracking’ which meant tracking the support the three residents receive through checking their records, observation of care practice and discussion with staff. Due to the limited communication and understanding of the residents living at the home the inspector did not converse with residents but observed staff interacting and communicating with residents. Staff records were looked at and a partial tour of the premises also took place in order to assess environmental standards. Two staff members were spoken with and the manager was available for discussion and feedback throughout. Judgements made in this report are not only from what was found on the day of the inspection but also based on information and evidence gathered over the year. This includes the pre-inspection questionnaire and residents and relatives surveys. Overall the inspection found there to be very positive outcomes for residents. What the service does well: Prospective residents do not move to the home until their needs have been assessed and action is taken when staff acknowledge that the home may no longer be suitable for meeting current residents’ needs. Care plans and risk assessments are thorough and provide detailed information on how residents’ needs are to be met. Step-by-step guidance is provided on how to support residents with their personal care and individuals’ preferences are included, which is good practice. It is evident that staff are committed to promoting choices and enabling communication with residents. Specialist health and social care professionals are accessed when necessary to help in meeting the needs of residents. Residents have good opportunities to participate in meaningful and fun activities both in the home and in the community and staffing levels are flexible enough to allow this. Residents are supported to maintain contact and relationships with family and other significant people. There is an appropriate complaints procedure in place, to ensure that residents and their representatives’ views are listened to and acted on. To assure that residents are safeguarded from abuse the Nottinghamshire Policy and Procedures are adhered to. Training and support for staff is good, which ultimately the residents’ benefit from and staffing levels are appropriate to the needs of residents. The environment is clean and the décor is maintained to a satisfactory standard. The lounge is very pleasantly decorated and furnished. Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 6 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. Thyra Grove Care Home DS0000002257.V299888.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.V299888.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 4 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a robust admissions procedure in place, which ensures that the home is suitable in meeting the needs of prospective residents but more information must be available to prospective residents so that an informed decision about moving to the home can be made. EVIDENCE: There is currently a vacancy at the home, which a new resident is due to be moving to very soon. The placing authority’s community care assessment along with updates have been supplied to the home and there have been meetings with the social worker and other health and social care professionals involved in this individual’s support to consider risk and support issues, to ensure the placement goes smoothly. The prospective resident has had two tea visits as an introduction and this time has also helped the current residents get to know their new fellow resident. There is information available about the home but it is recommended that the Statement of Purpose be presented in a way that ensures all items as specified under Schedule 1 of the Care Home Regulations are included. A new placement is still being sought for one of the current residents by the placing authority, as the home is no longer appropriate in meeting this resident’s needs. Thyra Grove Care Home DS0000002257.V299888.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 Quality for this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. There are excellent arrangements in place for ensuring that individuals’ needs and choices are met, and that risk assessments promote safety but also independence and quality of life. EVIDENCE: Residents have support plans that cover all aspects of personal and social support and healthcare needs and these are regularly reviewed. Support plans provide detailed guidance to staff on how the needs of residents are to be met and staff spoken with value the regular staff meetings for the purpose of discussing residents needs and support. Staff spoken with explained the communication needs of certain residents, which were reflected in their respective support plans. Support plans make reference wherever possible to enabling residents to make choices and when asked, staff spoken with gave good examples of how this can be achieved, for example, using pictures, photos, actual items and signs. Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 10 As well as necessary risk assessments for the usual health and safety issues such as choking, bathing and falls there are also risk assessments specific to individuals and their chosen activities. For example, riding a bike. Thyra Grove Care Home DS0000002257.V299888.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality for this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. There is a commitment from the staff team in promoting residents’ rights and enabling residents to experience a fulfilling quality lifestyle. EVIDENCE: All of the residents attend day services and participate in activities appropriate to their individual needs. One resident continues to have one to one support from an outside agency that visits the home. Staff spoken with confirmed that this arrangement, funded by Social Services, is working very well. Other residents attend day centres in the area during the week. It was evident from speaking with staff and also by reading daily records that residents have ample opportunity to go out in the community such as walks in the local area, parks and trips down the pub. Staff spoken with gave good examples of how they assist residents in maintaining contact and relationships with family and friends. Family and friends are invited along to their birthday parties and staff will facilitate phone Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 12 calls and transport residents to see family. Staff members were observed treating residents with respect and interacting with residents, not just with each other. Support plans also make reference to respecting individuals’ privacy and dignity. Menu plans and records show a real improvement since the last inspection in the variation and nutritious value of meals provided. There is now a system in place for residents to have more involvement in choosing meals and helping, where possible with their preparation. Thyra Grove Care Home DS0000002257.V299888.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and personal support needs of residents are well met. Improvements to medicine management will ensure the safety of residents. EVIDENCE: Specialist health and social care professionals such as psychologists, continence advisor and occupational therapists are involved in residents care when appropriate and as recommended at the last inspection, there is reference of what specialist support is being accessed on individuals’ relevant support plans. Support plans provide detailed step-by-step instructions on how personal care is given to residents, which include their individual preferences. For example, liking lie-ins and enjoying having make up done. A resident has recently been provided by an occupational therapist with equipment to get in and out of bath. For residents that may at times require ‘as required’ medication to alleviate symptoms of anxiety there are care plans in place which state very clearly at what stage this medicine should be given. This safeguards their rights. Generally speaking there were clear instructions for the administration of medicines on the Medication Administration Records (MAR). For one ‘as required’ medicine it was not entirely clear, and how this is currently being Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 14 administered does not tally with the GP instructions. This needs to be clarified. It is recommended that instead of using the ‘ordering book’ instead attach a photocopy of the prescription to the MAR, as a way of checking that the instructions on the MAR correlate with the GP prescription. This promotes safe practice. There was some tablet medication stored in the medication cupboard, which is not accounted for. These drugs must either be returned or carried over onto medication administration records (MAR), as a means to providing an audit trail for medicines administered and received into the home. Thyra Grove Care Home DS0000002257.V299888.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is an appropriate complaints procedure in place, to ensure that residents and their representatives’ views are listened to and acted on. The Local Adult Protection Procedures are appropriately followed, which helps to assure that residents are safeguarded from abuse. EVIDENCE: There is an appropriate complaints procedure in place, which is also presented in signs and symbols that is more accessible to the residents living at the home. No concerns or complaints have been made since this standard was last assessed. The local Adult Protection procedures have not been invoked since the last inspection. Social Services are involved on an ongoing basis in supporting one resident that had made an unfounded allegation. Staff spoken with demonstrated an understanding of their role and responsibilities in terms of whistle blowing and in accordance with the local adult protection procedures. Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a hygienic and safe comfortable home. EVIDENCE: Since the last inspection a new kitchen has been fitted. On a tour of the premises the environment appeared clean and hygienic. Communal parts of the home are well maintained and pleasantly decorated. Bedrooms are personalised with individuals’ pictures and ornaments. Residents choose what colours they want their rooms painted. An Infection Control Nurse has given ongoing and essential advice on hygiene issues relevant to the home and staff spoken with understand their responsibilities in this area. The laundry facilities are appropriate to meeting the needs of residents and sited away from where food is prepared and served. Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality for this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staffing levels are appropriate to the needs of residents and training and support for staff is well managed, which residents ultimately benefit from. No progress has been made with ensuring documentary evidence proves recruitment practices protect residents. EVIDENCE: Although the staff team is down by two workers staff spoken with feel that this has not posed a problem. The rota confirmed this as all shifts are covered and there are still opportunities for increased levels so that residents can access the community. Staff are appropriately supervised and all staff spoken with said that they feel supported. The target of 50 of the staff team qualified to at least National Vocational Qualification level 2 has been achieved and training records show that staff have attended mandatory training as well as training relevant to meeting the individual and collective needs of residents. Training certificates however were not available as these are now held centrally. Copies of certificates are required otherwise this is not adequate evidence. At the last inspection a requirement was set to ensure all staff members have copies of references and evidence of a Criminal Record Bureau check on their Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 18 file. Now that the Nottinghamshire Healthcare Trust will soon be pulling out of the partnership with Nottingham Community Housing Association (NCHA) and the employment of staff is transferring over to NCHA copies of all of this information has now been sent to NCHA central office for checking, which means there is no evidence available in the home to confirm that recruitment practices protect residents. An agreement has not been reached between the Commission and Nottingham Community Housing Association over how recruitment is to be regulated. Therefore, this is an outstanding requirement. Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health, welfare and safety of residents are promoted and protected. The home is well run and systems for monitoring the quality of care are in place, to ensure the home is run in the best interest of residents. EVIDENCE: The provider is now carrying out its responsibility to conduct monthly monitoring visits. The home has recently had a quality audit; one of three that should take place over the year in accordance with Nottingham Community Housing Association (NCHA) policy and procedures. The registered manager reported that Nottingham Community Housing Association is looking at ways to develop a service user survey that is accessible to residents with a learning disability. It is recommended that in the meantime where residents are unable to fill out this form that information is obtained from relatives and representatives. Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 20 The fire log shows that all necessary fire safety testing and drills have been carried out. The servicing of equipment and electrical and gas systems are all up to date. At the time of the inspection the cupboard for storing hazardous substances would not lock, which in accordance with Health and Safety legislation is a requirement. The maintenance department were called and the lock was repaired before the end of the inspection. Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 21 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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 x Thyra Grove Care Home DS0000002257.V299888.R01.S.doc Version 5.2 Page 22 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 YA20 Regulation 13 Requirement Ensure that there are adequate arrangements for the recording, handling, safekeeping and safe administration and disposal of medicines received into the care home. This refers to: 1. Ensuring all medication received into the home is accounted for. 2. Ensuring administration of medicines is in accordance with GP instructions, and that ‘as required’ medication is clearly labelled so. Provide evidence as specified under Schedule 2 of the Care Home Regulations 2001 that two written references and a CRB check has been carried out before a staff member commences employment. This is an outstanding requirement from the previous two inspections, initial timescale 31/12/05 not met. Provide documentary evidence as specified under Schedule 2 of the Care Home Regulations 2001 of any relevant qualifications of staff members. DS0000002257.V299888.R01.S.doc Timescale for action 01/08/06 2. YA34 17, 19 01/08/06 3. YA35 18 01/08/06 Thyra Grove Care Home Version 5.2 Page 23 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 YA1 Good Practice Recommendations Update the Statement of Purpose, ensuring all items as specified under Schedule 1 are included. 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