Inspection on 26/10/05 for Tithebarn

This inspection was carried out on 26th October 2005.

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

The inspector 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 21/02/06

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 26th October 2005 10:00 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.V263632.R02.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 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 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) Royal Masonic Benevolent Institution 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.V263632.R02.S.doc Version 5.0 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. 09/03/05 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 32 residents with personal care only needs and 10 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 with ensuite facilities and 2 double rooms with 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.V263632.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection over one day. The total duration of the inspection was 7 hours. The inspector reviewed care records, such as care plans for 6 residents and reviewed general records such as medications, policies and procedures, staff training, staff recruitment and staffing levels. 10 residents, 2 relatives, 7 staff and the manager were spoken with. Additionally a brief tour of the premises was undertaken. What the service does well: What has improved since the last inspection? What they could do better: The Home will need to update the medications policy and make sure that all staff give, receive and record medications in accordance with the policy. The opportunity to identify the choices of residents less able to communicate their choices will need to be taken. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 6 Staff need to make sure that they appropriately store potentially harmful items such as cleaning fluids. 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.V263632.R02.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Tithebarn makes sure that the staff are aware of the needs of the residents before they move in order to make sure that the staff can provide the right care. EVIDENCE: All the residents are assessed before they move into the Home. The manager keeps the assessments to help decide what needs the residents have and how the Home intends to meet their needs. Information for the assessment is from a variety of different sources including the resident, social services and the resident’s families. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The manager and staff make sure that residents health care needs are fully met and contact the relevant health care staff as and when needed. Residents are dealt with, with respect and dignity. Care plans continue to develop and reflect the needs of the residents. The home needs a medication procedure in line with best practice guidance to make sure that safe working practises are in place EVIDENCE: Residents spoken with were very complimentary about the way staff care for them. One resident said, the staff here are lovely, they all treat me very nicely and make sure I have what ever I want. A relative stated that “the staff here are very good, I’m so glad my mum lives here I feel as though I can walk away knowing she’s safe and well cared for. They care that well that mum is a lot better since she’s moved here.” The inspector observed staff during the inspection speak with kindness and respect to the residents at all times. The residents care plans are written to reflect the resident’s needs, as such staff have clear instructions as to how to meet the residents care needs. The care plans are regularly updated to identify any changes to the residents needs. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 10 Some medications were not clearly documented on arrival in the Home or on being given to the residents. Some of the medications given to the residents were unclear as to the proper instructions and the way that staff should give them. There has been some improvement in the documentation of the medications and the areas that are in need of further development have been identified to the manager. A future pharmacy inspection may be arranged dependent on the improvements to the management of medications within the Home as identified in the next inspection. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 11 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): 12, 13, 14 and 15 Staff are welcoming and supportive of relatives. There are a variety of choices in activities and food available to the residents. Good records in some areas assist the staff to support the choices that residents make. Staff do make choices for residents less able to based on verbal information and run the risk of compromising these residents choices. EVIDENCE: The atmosphere between staff, residents and visitors was relaxed and warm. All resident’s files seen held clear family and contact details. A family member spoken with said staff “always make me feel welcome whenever I visit. I’ve been invited to stay for a meal if I want and they always make sure that I’m offered a drink”. A separate catering company now manages the kitchen and as such a number of the menus have changed. A full menu detailing a variety of choices is available. The menu is in the early stages of development and the head cook is spending time determining what preferences the residents have. Three residents thought that there “are good choices of food”, “plenty of choices” and “good food”. However a resident commented that they found the food “a little bland”. The majority of the residents are able to express their choices and regularly attend residents meetings that include the activities available in the Home and Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 12 food choices. The home provides entertainment such as trips out, quizzes and bingo. The activities co-ordinator has records that detail items such as “likes to read” for each resident. Although these are brief it is good practice that the staff member has undertaken to find out some of the residents choices. For residents less able to express their preferences staff made choices for them. This was not always based on resident’s personal preferences but on verbal information or what appeared to be most suitable for the resident. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 13 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): 18 The home has policies, procedures and training in place to safe guard residents from any potential abuse. EVIDENCE: Staff have been trained in the Protection Of Vulnerable Adults. Staff spoken with described a good understanding of the Protection of Vulnerable Adults and were clear that they would feel confident to report any concerns. All staff files checked held had satisfactory checks in place prior to their employment. The Home has policies and procedures that all staff have read and signed that detail how to raise any concerns. Three residents spoken with said “if I had a problem the staff would see to it”, “I’ve never had any concerns, the staff are very nice” and “ I’d make sure that I’d tell someone if I was worried, the staff are so good they’d fix any problems I had”. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The Home is well decorated and well maintained. Communal areas are comfortable and attractive. Resident’s bedrooms are decorated to suit their individual tastes. EVIDENCE: Tithebarn is decorated in a homely manner. Maintenance records show that any issues are addressed rapidly. The Home is regularly checked to make sure that any issues of maintenance can be identified and dealt with appropriately. A resident spoken with said, “it’s lovely here, my room is just how I want it”. Residents are supported to have familiar items of furniture and decoration in their rooms. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 There are sufficient staff to meet the care needs of the residents and additional staff are available to support the residents social needs. All staff are appropriately vetted before the start working in the Home. Staff receive a variety of training in several areas in order to gain competency in their job role. However two areas of training such as medications and control of substances hazardous to health had not been competently dealt with by staff. EVIDENCE: Staff detailed that they have a variety of training available and are supported to undertake training as they need or request. The Home has recently put into place senior carer assistants to undertake more of a management role. These staff receive training to a higher level and have specific training to meet their job role. Training is available and has been undertaken by staff in medication and control of substances hazardous to health. However staff had not managed either of these two areas in accordance with their training or the Homes policies and procedures. The staff records viewed show that the staff receive full and proper employment checks prior to commencing working, this includes, a Criminal Records Check, 2 references, proof of identity and evidence of their experience and training. The manager makes sure that there is sufficient staff available at all times. Staff were clear that they never think that they are short staffed and that the Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 16 team of staff supports each other very well. A resident said “there are always plenty of staff, sometimes too many”, another resident said “I’m never rushed, the staff make sure I have what I need and look after me very well. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 17 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): 33, 38 The manager and staff consult the majority of the residents on a regular basis and make sure that the Home is run in their best interests. Health and safety is well managed and appropriate with the exception of medications and control of substances hazardous to health. EVIDENCE: The manager and staff try to make sure that residents are aware of the management of the Home. Residents are invited to attend regular meetings and their points of view are recorded in the minutes. A resident said, “I’m asked what I want and the staff make sure I get it”. The Home has recently sent questionnaires to relatives and have used the findings of this to make improvements in the care and management of the Home. All staff receive training in Health and Safety and are generally aware of what they need to do to keep the residents safe. Individual risk assessments were Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 18 available for residents as needed and these were regularly updated. The manager monitors any accidents and makes sure that actions are taken that help in reducing any potential risks. Health and safety checks on the general environment such as fire equipment, hot water etc is all undertaken on a regular basis. It was noted that Home had left items hazardous to health unattended, this included hand scrub on a main corridor and washing up liquid in a kitchen both these areas were accessible by residents. Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 19 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 2 Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations The manager should review the auditing arrangements for medications in order to make sure that all staff are guided in meeting the policy and procedure. Additionally consideration should be made to providing additional support to all staff identified from the audits as not meeting the policy and procedure for medications including assessment of competency. 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. 1 OP14 2 OP38 Tithebarn DS0000017274.V263632.R02.S.doc Version 5.0 Page 21 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.V263632.R02.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!