Inspection on 27/01/06 for Thyra Grove Care Home

This inspection was carried out on 27th January 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 no outstanding requirements from the previous inspection report, but made 4 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 22/06/06

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 Unannounced Inspection 27th January 2006 12:45 Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 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.V270895.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 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.V270895.R01.S.doc Version 5.0 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 NCHA Manager post vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2005 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. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours on the 27th January 2006 and was the home’s second of two statutory unannounced inspections for this financial / inspection year. The focus for this inspection was to follow up requirements set at the last inspection and to assess the remaining key standards that must be assessed at least once over the inspection year period. Therefore, it is recommended that this report be read in conjunction with the previous report. The main method of inspection was called ‘case tracking’ which meant selecting three residents and tracking the care they receive through checking their records, discussion with staff and observing care practices. Due to the limited communication and understanding of the residents the inspector was unable to speak with the residents as part of the inspection. Two members of staff were spoken with and a tour of the premises took place in order to assess environmental standards. The manager was available for discussion and feedback throughout. 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 activities both in and outside the home. Staff feel that community access is good. The home has its own vehicle, which helps. 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. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 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.V270895.R01.S.doc Version 5.0 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.V270895.R01.S.doc Version 5.0 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): 2 and 3 Prospective residents do not move to the home until their needs have been assessed and for existing residents whose needs can no longer be met at the home then more appropriate placements are to be found. EVIDENCE: Copies of the placing authority’s community care assessment were seen on the files of the resident’s case tracked. The home currently has one vacancy, for which there has been some interest. The community care assessment has been obtained to help decide whether the home is appropriate for meeting this individual’s needs and also to assess their compatibility with the current residents living at the home. The manager reported that she is currently liaising with a social worker over a new placement for one of the current residents, as it is felt that the home is no longer appropriate in meeting this person’s needs. Necessary evidence such as incident records are being gathered to support this, which is good practice. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 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 Care plans are thorough, with good accompanying risk assessments, to ensure that individuals’ needs are met safely. Staff assist residents to exercise choices and make decisions about their lives. 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. 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. 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 one residents case tracked who likes to go out shopping there is a risk assessment for the use of escalators and a risk assessment for road safety and mobility, which justifies the need for this resident to always be accompanied when out in the community. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 10 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, 14 and 17 Residents have opportunities to participate in appropriate meaningful activities and to access the community. Improvements to meals are required. EVIDENCE: At the time of the last inspection one resident, with complex needs had been granted additional funding for thirty hours to provide daytime activities. Since then this funding now pays for one to one support provided by an outside agency that visit the resident at the home. Staff confirmed that this arrangement is working more successfully, giving more time to spend with all residents. Other residents attend various day centres in the area during the week. Both staff spoken with expressed their commitment to enabling residents to access community-based activities. One resident has recently been to see a football match and there are regular opportunities to go out for walks and for lunch. Residents have a support plan outlining their preferred activities and what they don’t like. For example it states on one residents support plan that they do not like crowds or noise. The menu book shows that chips have been planned for four times this week and three times next week. This provides neither enough variation nor a healthy diet and does not meet the dietary needs of residents as identified in Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 11 their support plans. In case of food poisoning and to evidence variation and choice, meal records must be more detailed including what vegetables have been served and which residents have had what alternative meals. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 12 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 and 19 Healthcare needs of residents are well met and personal support is given in the way that is required and preferred. EVIDENCE: It was evident from discussion with staff and from correspondence on residents’ files that specialist health and social care professionals such as psychologists, continence advisor and occupational therapists are involved in residents care when appropriate. However, as this is an important element of meeting individuals’ needs it is recommended that any external involvement be specified in the relevant support plans. Appointment records show that residents have regular health checks, necessary for promoting general good health. 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. Staff spoken with identified the importance of flexibility and choice when providing personal support. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 13 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 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. Since the last inspection the Nottinghamshire Policy and Procedures for the Protection of Vulnerable Adults have been utilised on one occasion. The Adult Protection Unit and the Commission were notified and in accordance with the Procedures Social Services, who take the lead in adult protection, were contacted to discuss any further action that would need to be taken. The disclosure was taken seriously and responded to appropriately and subsequently additional support plans have now been implemented for the resident concerned. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 14 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 and 30 Outstanding environmental and hygiene issues have now all been appropriately addressed. Overall the décor and furnishings have significantly improved, however, the kitchen is in urgent need of refurbishment. EVIDENCE: On a tour of the premises the environment appeared clean and hygienic. Since the last inspection an Environmental Health Officer was consulted over the installation of a larger sink in the ground floor toilet. This is now in place and subsequently the malodour identified as a problem at previous inspections has now been eliminated. An outstanding requirement regarding an additional sink in the laundry room no longer applies as the Environmental Health Officer confirmed that this would not be necessary, (and spoke with the inspector at the time). The first floor toilet and first floor bathroom have now been redecorated and the damp and mildew problem in one of the bathrooms has also been dealt with. There are risk assessments in place for residents’ access to the kitchen, which highlights when it is necessary to restrict access to the kitchen, due to infection control and ultimately the promotion and protection of residents health. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 15 There is new furniture in the lounge and some communal parts of the home have been pleasantly decorated, which makes the environment feel more comfortable and homely. The kitchen has not been decorated. There is wallpaper coming off the walls and the fronts of kitchen cupboards are missing. The furniture and fittings in the kitchen are looking tired and in need of replacing. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 16 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 Staffing levels are appropriate to the needs of residents and training and support for staff is well managed, which residents ultimately benefit from. More documentary evidence is needed to ensure that the recruitment practices protect residents. EVIDENCE: Currently the team are one full time support worker down but the manager and staff reported that there have not been any difficulties covering shifts. The staff rota was looked at and confirmed this. The additional support needed for one resident is now contracted out, which has ensured that this time does not overlap with normal staffing hours. Out of the sixteen staff employed at the home four already have their National Vocational Qualification Level (NVQ) level 2, one has NVQ level 3 and four are currently in the process of doing it. This means that the home is not yet but on its way to the target of 50 of the staff team qualified to at least NVQ Level 2. The manager showed a ‘training matrix’, which indicated that staff attend all necessary mandatory and refresher health and safety training. Other courses relevant to the needs of residents are also available and have been attended. A new member of staff spoken with confirmed that he has been on induction and has started the Learning Disability Award Framework (LDAF) foundation training. The staff files examined showed that regular supervision sessions Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 17 with staff are now being undertaken, which is an essential part of their support. It was apparent that the manager has made a huge effort to obtain all necessary records on staff files as specified in Schedules 2 and 4 of the Care Home Regulations. There was evidence on these files that the relevant checks i.e. two written references and Criminal Record Bureau checks have been undertaken. However, for a recently recruited staff member it was noted that the letter from Employment Services confirming the return of a satisfactory CRB disclosure is dated December 13th while the staff member commenced employment in November. The date of issue is not included in the letter. It is therefore not clear whether the disclosure was returned before they commenced employment, which is required. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 18 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 The manager’s fitness to run the home will be assessed fully during the process of her application to register as manager. Nevertheless evidence from this inspection suggests that the home is well run. There are systems in place for monitoring and reviewing the quality of care that aim to be underpinned by the views of residents. Improvements to fire safety practice mean that the health, safety and welfare of residents are promoted and protected. EVIDENCE: All staff spoken with only had positive comments to make about the style of management. The manager was described as being open, supportive and approachable. The manager has applied to register with the Commission and she is has already achieved five units of the National Vocational Qualification (NVQ) Level 4 Managers Award. Nottingham Community Housing Association (NCHA) has a number of systems for monitoring the quality of care. There are regular internal audits that use staff and residents from other services and also external audits. The home is signed up to the ‘Quality Tree’ a Nottingham initiative that promotes quality assurance based on the involvement of residents. This is difficult for a Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 19 resident group with extremely limited communication but ways to develop this are being looked at. As a provider Nottingham Community Housing Association is not fulfilling its duty in accordance with Regulation 26 of the Care Home Regulations. Following unannounced monthly visits to the home a report should be produced on the conduct of the care home and then a copy submitted to the Commission. At the last inspection it was identified, fire drills were not being carried out. In accordance with Fire Precautions Legislation a fire drill is required at least every six months. Fire safety records show that all necessary fire alarm and fire system tests are being undertaken and fire drills are now being done monthly. Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thyra Grove Care Home Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 3 X DS0000002257.V270895.R01.S.doc Version 5.0 Page 21 No 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 YA17 Regulation 16(2)(i) Requirement In accordance with Schedule 4(13) ensure menu records are detailed to evidence that meals are balanced, wholesome and nutritious and that meals meet the dietary needs of residents as specified in their support plans. Refurbish the kitchen to ensure that adequate facilities are provided for the storage of food and preparation of food. Better documentary evidence is required in order to satisfy the Commission that staff are not commencing employment until the return of a satisfactory police check, or, if they are this is following a POVA First Check. Monthly, unannounced visits to the home are required and subsequently a report on the conduct of the home submitted to the Commission. Timescale for action 28/02/06 2. YA24 16(2)(g) 30/06/06 3. YA34 17, 19 14/02/06 4. YA39 26 31/03/06 Thyra Grove Care Home DS0000002257.V270895.R01.S.doc Version 5.0 Page 22 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. 3. Refer to Standard YA17 YA17 YA19 Good Practice Recommendations Record who has had what alternative meals so to evidence that choice is always available. Identify food likes / dislikes and suitable meal options of residents, to ensure that what is provided is suitable and promotes the health of residents. Include on relevant support plans when health and social care professionals are involved in that individual’s care. 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