Inspection on 04/06/07 for Tithebarn

This inspection was carried out on 4th June 2007.

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

The inspector 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 21/02/06

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 Claire Lee Key Unannounced Inspection 2pm 4 and 5th June 2007 th 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.V342904.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 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.V342904.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tithebarn Address Moor Lane Crosby Liverpool Merseyside L23 2SH 0151 924 3683 0151 932 1917 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) www.rmbi.org.uk 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.V342904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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). Date of last inspection 21st February 2006 Brief Description of the Service: Tithebarn Care Home provides care and support for forty two older people. Care is provided for thirty two residents with personal (residential) care needs and ten residents who require nursing care. The home is located off a main road and provides easy access to Crosby and other local amenities. Local transport is accessible however the home does have its own minibus and company car for resident/staff use. There are four lounges and two dining facilities. One lounge is exclusively for residents who smoke. There are thirty eight single bedrooms and two double rooms all of which have en-suite facilities. Tithebarn is a part converted building and part new building, set in its own grounds. Residents have access to all areas of the home by stairs or passenger lift and there is a good standard of equipment to assist those who are less independent. A call bell system is fitted in all areas with an alarm facility for the residents. Tithebarn has extensive grounds to the front and rear of the property with ample car parking space. The gardens are well maintained with an attractive water feature and there is easy access for residents who use a wheelchair. There are also patio areas for residents to sit out in and enjoy the sunshine. The Royal Masonic Benevolent Society, a registered charity, owns Tithebarn. Only people with links to The Masonic Society are eligible to live in the home. These details are available on request in the form of a resident information pack. The fee rate is from £442.00 for residential (personal) care to £687.00 for nursing care. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced inspection. It was conducted over a two day period for a duration of approximately fourteen hours. Thirty eight residents were accommodated at this time and this included two residents who were currently in hospital. A partial tour of the premises took place and a number of the home’s care, staff and health and safety records were viewed. Discussion took place with thirteen residents, five staff, the home’s administrator, deputy manger and registered manager. During the inspection five residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. Interviews also took place with three relatives. All the key standards were inspected and also previous requirements and recommendations from the last inspection in February 2006 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents prior to the inspection and some were also left for health care professional and one relative to complete at the time of the visit. Comments included in the report are taken from the resident/relative survey forms and also during the site visit. What the service does well: Tithebarn presents with a very warm, caring and friendly environment and residents appeared relaxed and comfortable with the staff. It was evident through interviews, general observations and discussions that staff had a good knowledge of the residents’ individual care needs and the level of support required. During both days staff were observed spending a great deal of time with residents either on an individual basis or within a group. Care was seen to be given in a discreet sensitive manner and staff were patient and gentle in their approach. Feedback from residents and relatives was very good, comments regarding the service included: “Very good home” (relative) “Lovely staff” (relative) “You could not want for more” “Superb home to live in” “A lovely place to live in” Visitors were seen popping in at various times of the day and a bring and buy sale had been arranged in the afternoon which everyone was able to take part in if they wished. This was well organised and raised money for future outings for the residents. A relative reported that when they visit refreshments are always provided and that the staff are cheerful and very polite. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 6 Prior to admission the manager or deputy manager assesses residents’ health and social needs. Information collated is then used to the form the basis for the plan of care. Assessment documentation seen had been completed to a good standard and included key areas regarding the residents’ health and general well being. Care files were organised, the information easy to read and care plans identified the relevant care and support required. Attention is paid to recording basic needs such as dental, optical, hearing and foot care, which are so important to the care of an elderly person. Comments regarding the care included: “Excellent care” “Really good care by all the staff” “You could not want for better care and attention” “The staff help me when I need help and never mind what they do” “Absolutely excellent” “Most helpful nursing care and support” Residents interviewed confirmed that the daily routine was flexible and based very much around their wishes. A resident said, “The staff never mind what time I go to bed, they are very accommodating”. Other residents commented on the fact that they can choose what to do during the day and that there is always ‘something going on’ which they like. The activities co-ordinator is passionate about her role and it was evident that residents are offered an excellent variety of social activities. Residents are asked about their preferred interests when they take up residency and are encouraged to join in as much as possible. Feedback from residents was excellent regarding the social arrangements; the crossword sessions were described as great fun. Musical entertainment was provided on the first day of the inspection and as previously stated a bring and buy sale was held in the grounds on the second day. Residents have the use of a minibus and company car for outings and ‘in house’ activities include, pamper days, music, film shows, skittles, bingo, exercise glasses and art classes. Gentlemen attend Lodge meetings. A number of residents were seen to go out with their families and staff accompany residents for individual shopping when needed. Several ladies attend a local luncheon club. Residents were complimentary regarding the standard of meals served and stated that the cook provides ‘home baking’. Cakes were made for the bring and buy sale. Meals are served in the dining room or residents can receive them in their own rooms if preferred. The dining room tables had menus displayed; they were correctly laid and had small flower arrangements. Two residents commented on the fact that they enjoy sitting together in the dining room and it was evident that lunch was a social occasion for all those gathered. The main meal of the day is served at lunch time and alternatives are available. A resident said, “The food is first class, you could not have better”. Staff were observed to give assistance to residents with their meals in a discreet, unhurried manner. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 7 The manager had acted upon complaints/concerns and residents spoken with confirmed that they were confident that their views would be listened to and acted upon. The home’s complaints procedure was displayed for residents and relatives to view. Tithebarn provides pleasant accommodation. The lounges and dining rooms are attractively decorated and have suitable furnishings and fittings. The bedrooms on the nursing unit have modern décor and are equipped with special beds to provide pressure relief for the residents and to assist staff with their moving and handling requirements. The bedrooms on the residential side are older in appearance however maintained to a good standard. Residents had personalised their bedrooms with items from home and a resident who shares a room with her husband said, “Our room is lovely”. Residents and relatives reported that the building was always kept in a good state of repair and that all areas were cleaned daily. The gardens are very attractive and there is ample space for residents to take a walk and enjoy the grounds. Staff have access to a good standard of training in safe working practice areas to ensure they have the skill and knowledge to provide the care and support needed. A small number require training in first aid and food hygiene; this is discussed further under ‘what the home could do better’. Over 50 staff are qualified to a (NVQ) National Vocational Qualification Level 2 and 3 in care. The management of the home is of an excellent standard and the manager was able to demonstrate a sound understanding and knowledge of the home’s quality assurance processes and maintenance of health and safety practices to ensure the ongoing protection of the residents. It was evident that residents feel valued and that they feel well cared for by competent skilled staff. They are encouraged to be actively involved in all aspects of the service and the manager and staff respond to their wishes appropriately. What has improved since the last inspection? What they could do better: A very small number of staff need to attend courses in food hygiene and first aid. The manager stated that this would be organised over the next four months. Staff have training passports to evidence courses attended. These should be kept up to date, as they are a record of achievement. NVQ certificates should also be kept in staff files to evidence dates when NVQ courses are completed. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 8 Residents are able to administer their own medicines if they wish. Staff complete a risk assessment for this practice and residents are also asked to sign a disclaimer to ensure they are aware of the risks involved. The documents seen should list medicines to be self administered so that residents are aware of the medicines they are taking full responsibility for. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 9 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.V342904.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information regarding the service and the manager completes a pre admission assessment for residents. This ensures that staff can meet their health and social care needs. EVIDENCE: The Statement of Purpose is included in an information/application pack, which is given to residents prior to taking up residency. The pack has all the necessary information for older Freemasons and their dependants regarding the service. A resident interviewed confirmed that they had received enough information before deciding whether Tithebarn was suitable for them. Likewise a resident said, “I was well informed, shown around and made very welcome” Part two of the pack is given to residents when they decide to take up residency and this includes further details including financial arrangements, advocacy details and copy of the complaint procedure. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 11 The manager or deputy manager complete a care needs assessment for all resident prior to admission. The deputy manager was out on an assessment at the time of the site visit to meet a prospective resident. As part of the case tracking process three assessments were viewed for residents admitted since the last inspection. The assessment documents had been completed to a good standard and key areas identified included, mobility, personal hygiene, medical history, continence, medication, risk of falls, social/family background, sleeping, diet and moods. Residents are also asked about their sight, hearing, chiropody and dental needs, which are so important to the care of the older person. The assessment has a dependency scoring system, which assists staff with collating the information for the plan of care and assessing any potential risk. One care file evidenced an assessment from social services to provide staff with further assessment details. Standard 6 was not assessed, as Tithebarn does not provide intermediate care. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs were identified in a plan of care and medicines were administered safely to them. Residents were observed to be treated in a respectful manner. EVIDENCE: As part of the case tracking process five resident care files were viewed, this included care files for three residents admitted since the last inspection. Residents have an individual care file and the information was easy to read and available for staff and residents to view. Care documentation had been reviewed regularly to ensure the information was relevant and accurate. Consent and agreement to the care plan by the resident and/or their relative had been obtained and this was also subject to review. Care plans seen identified care and social needs. Key areas included information for personal care, diet, mobility, falls, skin care, medication, continence and social involvement. Care plans are also completed for any medical condition that may affect a resident’s well being. This was discussed in relation to a resident who had required antibiotic therapy for a recent illness. Care plans gave information to the staff as to the identified need, action required and evaluation of care Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 13 given. Supporting documentation including risk assessments for care of skin, use of bed rails, nutrition, moving and handling, bathing and care/support required at night, for example, use of call bell, preferred time of settling, level of assistance required. The risk assessments included detail of the control and preventative measures required to minimise the risk to the resident. A copy of the moving and handling assessment is also placed in resident rooms for staff referral. Residents are weighed regularly to record weight gain or loss and monthly healthy checks are undertaken to monitor their general health. Daily report sheets recorded the day given over a twenty four hour period by the staff. There was evidence of health care appointments and visits from doctors and district nurses had been recorded in the files seen. Residents interviewed stated that they could see their GP at any time and that they had regular appointment with a chiropodist and their own dentist and optician. A staff member was liaising with a GP at the time of the site visit to discuss a medication review as part of a resident’s ongoing care management. District notes are kept in the residents’ rooms and care files seen evidenced details of the care and treatment given. It was evident that residents were receiving a good standard of care to meet their individual needs. A relative reported that when their family mother was unwell, staff were very attentive and provided a good standard of care. Comments from the residents included: “Very good care and support” “The care is excellent” “I have no worries about the care I receive” “Recent illness - the care received was excellent. Nothing was too much trouble” “Good liaison between home, doctor and relative” A medication administration policy is available and this includes guidance regarding residents who to administer their own medicines. A staff member interviewed stated that a number of residents on the residential unit like to continue with this practice as part of maintaining their independence. If a resident wishes to administer their own medicines then staff complete a risk assessment to ensure the resident can administer their own medicines safely. Residents are asked to sign a disclaimer to ensure they are aware of the risks involved. The documents seen should list medicines to be self administered so that residents are aware of the medicines they are taking full responsibility for. Residents have a lockable facility in their rooms for their safe storage. The two medicine trolleys seen were locked when not in use and controlled medicines stored appropriately. A list is kept of staff signatures for those members responsible for medicine administration. Medicine administration training is given to staff as part of their training programme. The manager Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 14 continues to use a monitored dosage system, which is dispensed by a local pharmacist. Medication Administration Records (MAR) viewed had been correctly completed to record the details of medication received and administered to residents. Advice was given regarding the signing for PRN (as needed) medication, for example paracetamol, to ensure records were maintained accurately. A photograph was in place for each resident for identification purposes. Two members of staff check the medicine Temazepam, as it is medicine liable to misuse. This demonstrates good practice. Staff were observed to be very polite and helpful towards the residents and their relatives. Various aspects of care were given in a sensitive manner and it was noted that when transferring a resident in a hoist a great deal of attention was paid to ensuring their privacy was respected. A resident seen nursed in bed appeared comfortable and received regular attention from the staff. Residents interviewed stated that staff knocked on doors before entering and always spoke to them when coming on duty. One resident reported, “The staff are very polite indeed”. A member of staff was observed assisting a resident with their evening meal and this help was carried out in an unhurried and sensitive manner. Staff interviewed stated that respect, privacy and dignity are discussed during induction and that they are asked to read the home’s policy regarding this when they start work. Residents have a lock to their door and a number of doors were found locked, as the residents were not present. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise a great deal of choice and control over their lives and are offered a choice of well balanced and nutritional meals. EVIDENCE: Tithebarn has a very warm, welcoming atmosphere and an excellent rapport was noted between the staff, residents and their visitors. There was lots of laughter and banter. A number of residents said that the staff made it a happy place to live and that the social arrangements could not be bettered anywhere. They also confirmed that that the lifestyle experienced was relaxed and geared towards their needs and preferences. Residents were seen having varying degrees of assistance from staff however this was based on their individual need. Staff interviewed were very aware of the importance of promoting independence where possible. The activities co-ordinator is assigned twenty fours a week to arrange and provide residents with a varied social programme. All residents interviewed were complimentary regarding the standard and frequency of events arranged. A calendar displays the activities of the week and care records record whether the resident has taken part and enjoyed the event. A small booklet is being Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 16 given to residents to complete regarding their life prior to coming to Tithebarn and this includes room for photographs and other items of interest. Not all the residents wish to complete one however staff respect their decision. In house activities include pamper day, bingo, skittles, crosswords, hangman, art classes, film shows, musical entertainment, art classes, visits by the Friends of Tithebarn (volunteer group) and exercise classes. In the past a resident has been taken to Anfield football ground and another resident had a trip in a small local airplane. Trips out are arranged during the warmer months and the residents are accompanied by the Friends of Tithebarn and staff. Residents have the use of a minibus and company car for outings and attending hospital appointments if needed. A social event has been arranged at Formby Hall for later on in the year. Several ladies attend luncheon clubs and the gentlemen attend Lodge meetings. A number of residents were out with their families, a number were having a stroll round the grounds and others were taking part in the bring and buy sale which took place in the afternoon. The money raised is being put towards future social events. An organist was playing on the first day of the inspection and recently an Irish Pipe Band visited the home. An art teacher provides art lessons and a resident has artwork on show by the dining room and also in their room. Photographs of recent social events are displayed and comments regarding social arrangements included: “Fantastic” “There is something going on each day” “Mary (activities co-ordinator) is marvellous” “I love the music” “The art classes are very good” “We have garden parties and fetes arranged in the summer” “Crosswords each Monday morning, with most of the residents taking part. Then there is the 30-question quiz, which we all enjoy. Another day we have team quizzes which is well enjoyed” “Activities co-ordinator arranges a variety of activities all may take part in. The Masonic gentlemen come in every Wednesday to organise bingo party” Residents confirmed that the hairdresser visits each week and there is a small hairdressing room for this service. Holy Communion is offered to residents each month to enable them to continue with their chosen faith and one resident attends a local church on a Sunday. Church leaflets were distributed at the time of the visit. Residents had personalised their rooms with pictures and personal possessions and friends and relatives were observed to visit residents throughout the day in the communal rooms or in the privacy of their own bedroom. The menu was displayed in the dining rooms for residents to choose what they would like to eat. They are also advised of the menu when they take up Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 17 residency as these details are provided in a welcome pack. The menu is based over four weeks and residents are offered wholesome nutritious meals. The cook prepares a summer and winter menu and takes on board suggestions from the residents as to the meals they would like served. Residents can write their suggestions and place them in a suggestion box. A resident requested black pudding and this was put on the menu. Staff ask residents what they would like from the menu each day and an alternative is available at each mealtime. The main meal is served at lunch time and a light lunch is also offered to residents if they would prefer a smaller meal. A number of residents attend the dining room however some prefer to stay in their rooms and this is respected by the staff. Lunch was observed as a very social occasion where residents get together for a chat. Lunch was served in an unhurried manner. The dining room tables were attractively laid and there were flower arrangements on each table. The cook was busy baking cakes and pies for the bring and buy sale which was held in the afternoon. Residents interviewed stated that the food was excellent and that they are always offered a good choice of fresh fruit and vegetables. Fruit bowls were available in the dining room. Special diets are catered for and a resident was celebrating a very special birthday with a cake and champagne. The cook attends the resident meetings to receive feedback regarding the meals and residents interviewed stated that the cook was willing to bake anything they wanted. Resident dietary preferences are recorded in the care files and this information made available to kitchen staff. It was evident that a great deal of thought is paid to providing a wide range of foods to suit individual likes. ‘Around Britain’ meals are served with produce from the different areas, for example the county of Suffolk and strawberries are on the menu for the Wimbledon fortnight. Comments regarding the food included: “Very good food” “Such a good choice” “The meals are served nicely” “You could not have better “ “Excellent meals” “Each one’s birthday is noted and celebrated” Kitchen staff were busy preparing lunch and baking cakes for the bring and buy sale however the kitchen was clean and organised. Environmental health records seen were up to date. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Polices and procedures are in place to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The complaint policy is displayed for residents and/or their relatives to view. Residents and relatives interviewed had no concerns at this time and reported that they would speak to the manager if they were at all unhappy. Complaints are logged and are audited by the Business Operations Manager. Senior management are always notified of any complaints or concerns received. A complaint investigated by the manager also came to the attention of the Commission. The complainant had been unhappy with the manager’s initial response however following further investigation by the manager the complaint has now been closed; it was found to be partially upheld. The manager has met with the complainant to discuss the findings and subsequently the complainant advised the inspector that they are satisfied with the care provision at this time. They stated that they would liaise with the manager if they have any further concerns. A staff member interviewed said that they knew what procedure to follow should a resident wish to make a complaint. Staff have access to an adult protection policy and also Sefton and Liverpool’s Adult Protection Procedures. A copy was available in the main office and also the nurses’ office. Staff receive adult protection training and a staff member interviewed knew what to do should they witness an alleged incident. Training Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 19 in adult protection was last given to new staff in April 2007. Two adult protection cases were reported to the Adult Protection Team and were found to be unsubstantiated. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in pleasant, safe, comfortable and well-maintained surroundings. EVIDENCE: Tithebarn is a comfortable, clean home that is pleasantly furnished and decorated. Areas seen had been maintained to a good standard and the maintenance person completes every day jobs and repair work. The home has a large hall, which has plenty of information regarding the service, and visitors and residents are asked to sign in and out of the building. There is also an aquarium and large grandfather clock in the hall. Records were available to confirm that health and safety checks of the building and the external grounds are well maintained. Residents reported that they enjoy sitting out on the patios, which have plenty of benches and garden chairs. There is also a large attractive pond with lots of ducks that visit the residents. Wheelchair access is available to the grounds. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 21 The lounges and dining rooms are attractively decorated. There are comfortable armchairs and coffee tables and the dining room tables are laid for each meal. Residents who wish to smoke use one lounge and there is a large widescreen television in the main lounge. The main corridor on the ground floor on the residential side is in need of painting as certain areas are scuffed. The manager confirmed that this maintenance is ongoing. Residents have the use of small kitchens equipped with a fridge and kettle if they wish to make their hot or cold drinks. It was reported that not many residents use this facility however it is there to promote the residents’ independence. Staff stated that there is a good standard of equipment and this includes moving and handling hoists and variety of walking aids. Bathrooms are suitably adapted to assist those less able and this includes a parker bath, medi bath and hydro bath. The hydro bath is a new addition and staff stated that residents really enjoy using it. There are walk in showers if preferred. The bathrooms were found to be very clean and odour free. The corridors on the residential unit are narrow however they do provide access for wheelchairs. Wheelchairs seen had footrests in place to minimise the risk of injury to the resident. A resident interviewed had a special phone with large push buttons for easy use. Bedrooms viewed had been personalised by the residents with items from home and residents interviewed stated that they were comfortable and cleaned regularly by the staff. The bedrooms on the nursing unit are more modern and are equipped with special beds, which are beneficial for residents with high dependency needs. The bedrooms on the residential side are older in appearance and subject to a more regular programme of redecoration. Residents have lockable storage space for their valuables and medication. They are also able to lock their bedroom door if they wish. This was evidenced at this time. All rooms have a call bell and a resident reported that the call bell was, “Always answered within two minutes”. Likewise another resident said, “Can ring anytime and discuss things with home manager, nurse or carers”. Emergency lighting is checked monthly in house and is subject to an annual safety contract. Checks of the hot water temperatures to the baths are undertaken to ensure the hot water is delivered to a safe temperature. Records seen were current. The laundry room was tidy, clean and organised. Infection control training is given to staff to ensure they are familiar with the correct procedures to be followed. Residents reported that the care of their laundry was good and that clothes were returned promptly. Comments regarding the accommodation included: “Nice home to live in” Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 22 “My room is cleaned each day” “It is very comfortable” “The grounds are lovely” “I have everything I need in my room” Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of skilled and trained staff are employed via robust recruitment procedures to provide care and support to the residents. EVIDENCE: The staffing rota was seen for the month of June 2007 and this evidenced sufficient numbers of staff on duty. A registered nurse is on duty twenty fours a day for the nursing unit and provides support and advice to staff on the residential side as needed. The manager is supported by a full compliment of staff including a deputy manager (who is also a registered nurse) and an administrator. Three shift leaders take charge on the residential side and they provide support to the other care members. One shift leader has completed NVQ Level 4 in Management. Bank or agency staff may be used on occasions to cover any outstanding shifts. Residents confirmed that staffing levels were good and that staff were around to help when needed. Sufficient numbers of staff are employed to ensure a good standard of cleanliness in the building. A resident said, “My wash room is cleaned every day, my carpet hoovered and my furniture polished”. Domestic staff have the use of a trolley for their cleaning products and gloves and aprons were being used appropriately. COSHH (Control of Substances Hazardous Substances) data is kept for cleaning products however not all staff were aware of where Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 24 this information is located. This was brought to the manager’s attention as a training issue. Staff have a key worker role and a number of senior care staff are shift leaders. The key worker role enables staff to get to know the residents better when providing care and support. The pre inspection questionnaire evidenced that 60 of staff have achieved an NVQ (National Vocational Qualification) at Level 2 and above. Not all staff files viewed evidenced a certificate for their qualification and this information should be kept in staff files to evidence their training. Four staff files were viewed to evidence recruitment practices. The staff members had been recruited correctly to ensure the ongoing protection of the residents. The files contained completed job application forms with details of past employment, two references, POVA (Protection of Vulnerable Adult) check and CRB (Criminal Record Bureau) enhanced disclosure. References had been obtained from past employers where needed. Staff are provided with a handbook, contract and job description. Registered nurses have a current PIN (Personal identification number) for the NMC (Nursing Midwifery Council) to enable them to practice safely. New staff receive an induction and the manager now has the new documentation to commence the Skills for Care Induction Standards, which have replaced the TOPSS (Training Organisation for Personal Social Services) induction standards, which were withdrawn last year. There was evidence of induction in staff files viewed and also a record was seen of the TOPPS inductions completed from 2003-2006. Two staff members confirmed that they were shown round the home when they started, that the fire procedures were discussed at length with them and that they worked with an experienced member of staff. Staff receive training in safe working practices including, moving and handling first aid, food hygiene, infection control and health and safety. The staff have individual training passports to evidence courses undertaken however these are not kept up to date. Staff should complete these are they are their own record of achievement. The manager has a training record on the computer to evidence training undertaken. There was evidence of a rolling programme for courses in safe working practices however when reviewing staff files it was noted that two members of staff require food hygiene and one member of staff first aid. Two domestic staff members have not received first aid and this training should be rolled out to them when possible. The manager stated that the training required would be arranged over the next four months. Moving and handling is booked for July 2007 and a new staff member is attending at this time or earlier if it can be arranged. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 25 Staff interviewed said that the manager arranges a good training programme. Other study days attended include, diabetes, medicine management, dementia care, nutrition in the elderly and artificial feeding. The activities co-ordinator is undertaking an aromatherapy course to give massages and Jacuzzi/hydro therapy treatments to the residents. Residents interviewed were pleased with the standard of care given by the staff and said that they were well trained and professional in their approach. A resident said, “The girls are really good indeed”. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,36 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is experienced and qualified to manage the service effectively and seeks the views from the residents to provide a quality service. Policies, practices and procedures are in place to safeguard the health, welfare and safety of residents and staff. EVIDENCE: Ms Linda Johnson is the registered manager and she is also a registered nurse with a current registration with the NMC (Nursing and Midwifery Council). Ms Johnson has completed NVQ Level 4 in Management and also the A1 Assessor’s course for NVQ. Ms Johnson has worked at the home for a number of years and is supported by a deputy manager, Ms Sue Burge who is also a registered nurse. Ms Burge has also completed management courses to assist with her role. Residents, staff and relatives were very complimentary regarding Ms Johnson’s management of the service and her willingness to take on board new Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 27 ideas. A staff member said, “You can knock on Linda’s door at any time and she always listens to what you have to say”. A number of visitors and staff members were seen going to the office and good communication was evident at all times. It was evident that both managers work closely to monitor the standard of care given to residents and that they are person centred in their approach. Ms Johnson provides a quality service based very much based on what the residents need. A resident said, “The whole management of the home is excellent, we do not want for anything and we are in good hands”. A Business Operations Manager who visits the home on a regular basis supports Ms Johnson. The Friends of Tithebarn also help arrange the social events and are actively involved with fund raising. There is an annual development plan and this was discussed in relation to the maintenance plan for the building. Work needed is identified and meetings are held with the estates manager to discuss this further. A record was seen for a recent meeting. The manager has objectives and receives supervision from her line manager. The manager also conducts supervision with the staff and those interviewed confirmed that that they can discuss staff training at this time and their own personal development. There was evidence of staff appraisals on file. Residents interviewed confirmed that their opinions are sought regarding the service and that in the past they have received survey forms for this purpose. The surveys were not available at the time of the site visit, as the manager stated that they were kept by the external auditor who conducts the review and provides an external star rating of the service. A summary of the residents’ views was however available in the form of percentages and these identified satisfaction all round. The findings of the surveys are available for staff and residents to view and the manager confirmed that surveys would also be going out later this year as part of the quality assurance process. The Business Operations Manager conducts Regulation 26 visits and a report is written following the monthly visit. The report is a care operations monthly audit and it involves talking with resident, staff, viewing the building and reviewing a number of records including the complaint file. The manager also completes a number of monthly audits of the service and this includes the care plans and medicines to ensure the care files contain sufficient detail and medicines are administered safely. This demonstrates good practice. Staff and resident meetings are held and minutes were seen for the resident meeting in April 2007. A resident said, “The manager Linda Johnson holds resident meetings quite regularly at which we can air our views and complaints”. The cook attends the meetings and residents are able to discuss the menu at this time. Following one of the meetings it was decided that residents can choose what meal they would like for their birthday as part of expanding the menu. Social events are discussed at the meetings to enable residents to become fully involved with the arrangements. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 28 The administrator takes care of residents’ finances and records seen were up to date and in good order to protect the residents’ financial interests. Staff have access to a good range of policies and procedures and these are updated periodically. Staff have to sign to say they have read the policy of the month and understood its contents. The policy for this month is smoking as the manager feels this is relevant with the changes that are coming on board with regard to smoking in public places. The policy for confidentiality, equal opportunities, sexuality and personal relationships was viewed. There has been no formal equality and diversity training however the manager and staff are aware of addressing this within the assessment and care planning process and by also ensuring the individual cultural needs, beliefs, values and wishes of the residents are respected. Pre-inspection records detailed that equipment within the home was regularly inspected and serviced. As spot check was undertaken of the gas, electric, lift and moving and handling equipment. Certificates seen were current. Fire records were examined. Records confirmed that the fire alarm system was tested on a weekly basis and the emergency lighting on a monthly basis. A certificate was in place to confirm the emergency lights, fire extinguishers and fire alarm system had been serviced. Staff receive fire training and dates of training had been recorded. Fire prevention is discussed during staff induction and followed up by formal training at regular intervals. Six members of staff are designated fire wardens. The fire risk assessment of the building is due to be updated in June 2007 and a health and safety inspection is undertaken by a private company to ensure the ongoing protection of people who use the service. The accident book records incidents that affect the welfare of the residents and staff. An accident record was viewed and this contained good detail as to the n nature of the incident and treatment given. The manager and senior management monitor care practices to establish whether the incident could have been avoided and all accident records are audited. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 29 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 4 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 3 3 3 X 3 Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 30 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. 1. 2. Refer to Standard OP9 OP28 OP30 Good Practice Recommendations The risk assessment/disclaimer, which staff and residents complete for self administration of medicines, should list the medicines to be administered by the resident. NVQ certificates should be kept in staff files to evidence details of the course completed. Staff training passports should be kept to date to evidence courses undertaken. Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tithebarn DS0000017274.V342904.R01.S.doc Version 5.2 Page 32 - 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. 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