Inspection on 21/02/06 for Tithebarn

This inspection was carried out on 21st February 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tithebarn 04/06/07

Tithebarn 26/10/05

Tithebarn 09/03/05

Tithebarn 09/11/04

Tithebarn 30/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Tithebarn Moor Lane Crosby Liverpool Merseyside L23 2SH Lead Inspector Mrs Julie Garrity Unannounced Inspection 21st February 2006 10:10 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 Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 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. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tithebarn Address Moor Lane Crosby Liverpool Merseyside L23 2SH 0151 924 3683 0151 932 1917 ljohnson@rmbl.org.uk arichards@rmbi.org.uk Royal Masonic Benevolent Institution 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) Ms Linda Christine Johnson Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 42 OP. Maximum no. registered - 42, of which up to a maximum of 32 PC (personal care) and up to a maximum of 10 N (nursing). Manager to obtain NVQ Level IV in Management or equivalent by 2005 One additional nursing care place available for a named service user only. Therefore, bringing PC (personal care) places down to 31 and N (nursing) places up to 11. The variation to nursing places is for the named service user only, should the service user leave the home then the variation will cease. The variation for the additional nursing care place is to be reviewed in 6 months and extended for the named service user only, if required. 5. Date of last inspection Brief Description of the Service: Tithebarn Care Home provides care for 42 older age service users. Care is provided for 31 residents with personal care only needs and 11 residents needing nursing care. There are four lounges and two dining facilities available for the residents. One lounge is exclusively for the usage of residents who smoke. There are 38 single bedrooms and 2 double rooms all of which have en-suite facilities. Tithebarn is a part converted building and part new building, set in its own grounds. The gardens are well maintained and accessible by residents. The Home is owned by the Royal Masonic Benevolent Society, a registered charity. Only people with links to The Masonic Society are eligible to live in the Home. These details are available on request from the Home. The Home is located off a main road and provides easy access into the Crosby shopping area. Ample parking is available and local transport is easily accessible. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection undertaken by on inspector over a day. The total duration of the inspection was 3 hours. An additional a pharmacy inspection was undertaken at the request of the manager. CSCI inspects “core” standards over 2 inspections. The core standards not covered in this report were covered in the previous report undertaken on 26/10/05. The inspector undertook this inspection by reviewing on-site records such as medication records, resident’s finances, daily records, resident’s financial records, and staff training and staff recruitment records. Other records reviewed were previous reports and CSCI records such as notifiable incidents and provider visit reports. Discussions were held with 7 residents, 2 relatives and 4 staff. The inspection was undertaken with the support of the manager and all areas were discussed with the manager as they occurred. Full feedback was given to the manager at the end of the inspection. There were no requirements from the previous report, three requirements pertaining to medications was made in this report. What the service does well: What has improved since the last inspection? The home continues to maintain the environment well a number of areas such as the kitchen have had equipment replaced. There are plans to renew other areas such as laundry flooring. The Kitchen staff make sure that all food items are clearly dated to make sure that the food is generally fresh and menus have been further developed to reflect the residents choices. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 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 Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 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): None of the standards in this area were fully reviewed at this inspection. EVIDENCE: Tithebarn has admittance criteria for residents that include an association with the Royal Masonic Benevolent Society. This is information that is clearly identified in the Statement of Purpose and service users guide. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 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 Minor shortfalls were evidenced in the recording and handling of medication. EVIDENCE: The manager requested a pharmacy inspection for medications for advice and guidance. This was undertaken as part of the homes inspection. A separate report is available for on request. 3 requirements were made from the pharmacy inspection and are included with this report. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 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): None of the standards in this area were fully reviewed at this inspection. EVIDENCE: Residents spoken with were very happy with the care that they received and the way that the home was run to meet their needs. One resident said, “I get to do what I want. Staff know the way I like things and make sure that it happens”. Another resident said “I prefer to be in my own room, its just to busy in the lounge. Staff make sure that I’m comfortable and check I’m okay during the day”. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 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 Residents and relatives are confident that their complaints are listened to and taken seriously. EVIDENCE: The home has information on making a complaint that is available to all residents and their relatives on admission. Residents raise concerns informally rather than in writing and the home addresses their concerns. A recent complaint raised by a resident was taken seriously by the home. The manager made sure that relevant parties such as family and social services were contacted and a full and proper investigation was undertaken. The manager made sure that any concerns that the residents or their families had were addressed. One relative spoken with “when I’ve had even a minor issue the staff have bent over backwards to fix it, but to be honest there’s nothing to complain about it’s a lovely home”. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 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): 26 The home is clean, pleasant, hygienic and welcoming. EVIDENCE: A tour of the premises found Tithebarn to be pleasantly furnished, carpeted and decorated. The home is being maintained to a good standard. Discussions with residents and their families found them happy with the standard of accommodation within the home and in particular with their bedrooms. One resident said, “the home is always lovely and clean. There are sufficient sluices available for staff to be able to dispose of clinical waste. Although one of these was being used as a storage room and needed to be cleared with cleaning chemicals locked away. The laundry was clean and tidy as was the kitchen. Through out the home protective equipment such as gloves and aprons were available. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 13 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): 28 Residents are in safe hands at all times. EVIDENCE: The manager and staff are aware of the needs of the residents in a variety of areas. Good management practice makes sure that quality is strived for at all times. This includes making sure that staff undertake training specific to their role including training courses specific to care assistants such as National Vocational Qualifications. The manager has several staff who have completed this training with other staff waiting to start the course or nearly finished. Residents and relatives spoken with were confident that staff had the skills to do their job. One resident said “they are good at what they do” and a relative said, “the staff are always doing different training. It shows they are very good”. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 14 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, 35 The manager is registered with CSCI and makes sure that residents are protected, well cared for and that their views are the top priority. Resident’s financial interests are safeguarded. EVIDENCE: The manager is registered with CSCI. She has worked in the home for several years and has been the registered manager for the last three years. She is a registered nurse and has management qualifications. The manager makes sure that she maintains her own learning and undertakes a number of courses. Residents spoken with were very confident at her ability to manage the home, comments included “always happy to help”, “she makes sure that the home runs properly” and “very supportive to everyone”. There is a full policy regarding resident’s finances that is included in the information given to residents when they arrive in the home. Clear records are available that give residents information about what funds they have available. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 15 Residents are supported to manage their own personal allowances as appropriate. Residents can request that the home looks after their money and records such as receipts are kept to make sure that the money is managed in accordance with the resident’s choices. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 16 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 X X X X x HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 17 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 OP9 Regulation Schedule 3 3(i) 13(2) Requirement Timescale for action 21/03/06 2. OP9 13(2) 3. OP9 13(2) 13(4) c The registered manager must ensure an accurate record of all medicines administration is made with particular reference to incorrect audit trails, variable dose preparations, eye drops and cream application. The controlled drug cupboard 21/03/06 should be made fully compliant with the Misuse of Drugs (Safe custody) Regulations 1973. The registered manager must 21/03/06 ensure all residents that selfmedicate are appropriately risk assessed and reviewed on a regular basis. Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 18 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 OP14 Good Practice Recommendations The manager should make sure that residents who are less able to communicate should have their personal preferences, choices and wishes recorded. Staff should make decisions for using residents recorded choices rather than verbal discussions. The manager should make sure that substances hazardous to health are appropriately stored at all times. All signed prescriptions should be seen and checked by the home prior to the pharmacist dispensing. All medication not contained in the monitored dosage system should be dated upon opening to enable accurate audit trailing. Two members of staff should always witness the disposal of medication. All medicines patient information leaflets should be made available to staff for training and general information. The medication policy should be reviewed with particular reference to homely remedies, disposal of medication, management audits and self-medication. “When required” medication should be clearly highlighted in the care plans to ensure staff take a consistent approach. 2. 3. 4. 5. 6. 7. 8. OP38 OP9 OP9 OP9 OP9 OP9 OP9 Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Tithebarn DS0000017274.V283557.R01.S.doc Version 5.1 Page 20 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!