Care Home: Thornbury House

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What the care home does well The home provides care and support to enable service users to live meaningful lives and staff support service users in their day-to-day lives and they are treated as individuals and with dignity and respect. There is an effective care planning system in place and service users are supported to access the local community. Comments from service users included "I like living here" "the staff help me when I need it" and "I am very happy". We observed staff supporting service users and there was a good Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 rapport between service users and staff and from talking with residents and staff and from the comments received, residents were happy living at the home and we observed that staff and residents got on well together. The home has a dedicated staff team and there is a robust recruitment procedure, which helps protect service users. What has improved since the last inspection? This is the first visit to the service since the new providers took over the home. What the care home could do better: The report will make 3 requirements to help improve the service for residents and the report also contains details of other areas where the home could do better. We found that the homes medication policy gave some conflicting information and did not provide clear guidance for staff. The registered persons needs to review and amend the homes medication policy to give clear guidance for staff and to reflect the practice that takes place at the home. This will benefit both staff and users of the service. Currently there are no Controlled Drugs (CDs) kept at the home. However the home does not have a suitable cabinet to store CDs and we reminded the manager that should there be a need for any controlled drugs to be held at the home and to comply with the law, they must be stored in a proper Controlled Drugs Cupboard which meets the requirements laid down in the Misuse of Drugs (Safe Custody) Regulations 1973. We looked at the training records for staff and although staff had completed a number of training courses we found that some of the training certificates were out of date. The registered person needs to review the training needs of staff to ensure that staff receive training appropriate to the work they are to perform this will ensure that service users are appropriately supported There was no set procedure for the washing of any soiled items, the manager told us that she relies on staff to act appropriately and to wash items separately at appropriate temperature, but in order to help to control any cross infection issues the homes manager told us that she would ensure that clear procedures were laid down to provide guidance and advice for staff. Although staff carry out weekly checks around the home and note any problems or defects, there was no record of when defects have been reported or when they have been rectified. The registered person needs to develop anThornbury HouseDS0000073287.V376153.R01.S.docVersion 5.2effective system as the system currently used at the home does not provide evidence that defects are identified and rectified in a timely manner. Key inspection report CARE HOME ADULTS 18-65 Thornbury House 39 Thornbury Avenue Shirley Southampton Hampshire SO15 5BQ Lead Inspector Mick Gough Key Unannounced Inspection 6th July 2009 10:00 Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornbury House Address 39 Thornbury Avenue Shirley Southampton Hampshire SO15 5BQ 02380221165 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) Hosanee & Company Ltd Mrs Claire Fuller Care Home 6 Category(ies) of Learning disability (0) registration, with number of places Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD) The maximum number of service users to be accommodated is 6. Date of last inspection Brief Description of the Service: Thornbury House is a residential home providing care and accommodation to six younger adults with Learning Disabilities. The home is a large domestic style house that blends well with other homes in the local area and does not stand out as a residential home. Each service user has a room of their own that has been decorated to meet their individual preferences. The home is arranged over three floors, comprising of six single bedrooms, bathing and toilet facilities, kitchen/diner, lounge, utility and good sized enclosed garden. The home is situated in Shirley, a residential area of Southampton. It is close to Southampton City Centre and Shirley High Street. The home is local to Southampton Common and Southampton Sports Centre with its attractions and where community events are held. There is a small secure garden to the side and rear of the house that is accessible to the people using the service. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. This report details the evaluation of the quality of the service provided at Thornbury House and this is the first visit to the service since new providers took over the home in January 2009. The inspection took into account the homes Annual Quality Assurance Assessment (AQAA), which arrived when we asked for it and was completed satisfactorily. The AQAA is a self assessment tool that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Included in the inspection was an unannounced site visit to the home, which took place on the 6 July 2009 between 0930 and 1430. We sent out surveys to 5 service users and 5 members of staff and received responses back from 3 members of staff who when asked “ does your manager give you enough support and meet with you to discuss how you are working” all answered yes. Staff answered positively to all of the questions in the survey. All of the service user surveys were completed with the help of staff and again these were all positive about the service provided. For this visit we involved 3 users of the service and 3 members of staff who provided us with information about the home and other evidence for this report was obtained from reading and inspecting records, including pre admission assessments, plans of care, training and recruitment records and some of the homes policies and procedures. We also observed the interaction between staff and users of the service. The manager of the service assisted us throughout the visit. The home is registered to provide support for 6 service users and at the time of the inspection there were 5 people living at the home. What the service does well: The home provides care and support to enable service users to live meaningful lives and staff support service users in their day-to-day lives and they are treated as individuals and with dignity and respect. There is an effective care planning system in place and service users are supported to access the local community. Comments from service users included “I like living here” “the staff help me when I need it” and “I am very happy”. We observed staff supporting service users and there was a good Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 6 rapport between service users and staff and from talking with residents and staff and from the comments received, residents were happy living at the home and we observed that staff and residents got on well together. The home has a dedicated staff team and there is a robust recruitment procedure, which helps protect service users. What has improved since the last inspection? What they could do better: The report will make 3 requirements to help improve the service for residents and the report also contains details of other areas where the home could do better. We found that the homes medication policy gave some conflicting information and did not provide clear guidance for staff. The registered persons needs to review and amend the homes medication policy to give clear guidance for staff and to reflect the practice that takes place at the home. This will benefit both staff and users of the service. Currently there are no Controlled Drugs (CDs) kept at the home. However the home does not have a suitable cabinet to store CDs and we reminded the manager that should there be a need for any controlled drugs to be held at the home and to comply with the law, they must be stored in a proper Controlled Drugs Cupboard which meets the requirements laid down in the Misuse of Drugs (Safe Custody) Regulations 1973. We looked at the training records for staff and although staff had completed a number of training courses we found that some of the training certificates were out of date. The registered person needs to review the training needs of staff to ensure that staff receive training appropriate to the work they are to perform this will ensure that service users are appropriately supported There was no set procedure for the washing of any soiled items, the manager told us that she relies on staff to act appropriately and to wash items separately at appropriate temperature, but in order to help to control any cross infection issues the homes manager told us that she would ensure that clear procedures were laid down to provide guidance and advice for staff. Although staff carry out weekly checks around the home and note any problems or defects, there was no record of when defects have been reported or when they have been rectified. The registered person needs to develop an Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 7 effective system as the system currently used at the home does not provide evidence that defects are identified and rectified in a timely manner. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users can be confident that there will be a detailed assessment of their individual needs before they move into the home. EVIDENCE: The homes AQAA and also information gained at the site visit showed that there has been one new service users admitted to the home in the last 12 months. The home has a clear admissions policy and the manager informed us that she would always carry out an assessment of any potential new service user and also obtain social service assessment before anyone moved into the home. We looked at the assessment of the most recent service user and this showed that the service user moved to the home from another care home in Southampton, there was records of visits to the home and these included overnight and weekend stays. The home was provided with information about the individuals care needs from the previous home and also the homes own assessment together with the social service assessment formed the basis for the person plan of care. The service user moved in on a 3 month trial basis and there was a review after 3 months to see how the service user was settling in at the home and also to see how the home was meeting the individual needs. This service user has now been at the home for over 12 months. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users assessed needs and personal goals are set out in their individual plan of care and service users are involved in the care planning process as much as possible. Daily recording is good; however the monthly reviews of care plans do not show how the care plan is working for the individual service user. Staff at the home respect service user’s rights to be involved and make decisions about their day to day lives and service users are supported in this process by staff at the home and they are supported to take responsible risks. EVIDENCE: Care plans were seen for 2 service users and these were comprehensive documents that gave staff information on what support was required and how and when this should be given, there was information on the service users needs with regard to personal care, maintaining relationships, leisure, mobility, Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 11 communication, nutrition, health care, diet, behaviour, likes and dislikes and also personal goals. The manager informed us that service users were involved in the care planning process as much as possible and we saw that care plans were person centred. Both of the care plans seen reflected the needs and support required for each service user and were written clearly and could be followed easily. In the care plans viewed there was good information for staff on how to respond to any challenging episodes. Staff members who returned comment cards and those spoken to on the day of the visit felt that care plans contained the information they needed to offer the right level of support to service users. Daily recording took place at the end of each shift and this gave good information on what support had been given to each service user and gave information on how the service user had been throughout the day. Each care plan had a monthly review but this was mainly just a signature and a date, with no evaluation on how the care plan was working for the individual and the recording did not always show that the service user had been involved in the monthly review. However each service user had an annual service review and these reviews included input from relatives, care managers, health care professionals and staff. Service users are involved in the review process as much as possible. Service users are encouraged and supported to make informed decisions as much as they are able. The home aims to give service users as much choice as possible and they use picture symbols, objects of reference and verbal communication to give service users choice in their day to day lives. We saw in daily recording that service users were offered choice and in the notes for one service user it stated “offered to take out for a walk but service user decided to stay in and watch TV” “ Service user asked to go out with staff to do the food shopping” “decided not to come down for lunch so had a sandwich in room and watched TV” We also observed staff supporting service users and they were able to make informed choices and staff respected their wishes and treated them with dignity and respect. Risk assessments are in place and are contained in care plans and there was information on how to manage any identified risks. We saw risk assessments for mobility, epilepsy, challenging behaviour and for supporting service users out in the community. The risk assessment for those service users who may challenge the service had good information on how to manage certain situations and minimise any risks and also gave staff information on some of the triggers that may cause the service users to become upset. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 & 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are encouraged and supported to be part of the local community and to be involved in appropriate activities. Service users benefit from support to maintain social contacts and daily routines at the home respect service users rights and responsibilities. Meals at the home are flexible and service users benefit from a healthy diet. EVIDENCE: None of the service users at the home attend any formal education classes or take part in any form of occupation. Two service users take part in cookery classes through the day service and staff at the home offer support to service users to develop independent living skills such as making drinks and snacks. Of the 5 service users 4 use day services between 1 and 4 times per week. Each service user has an individual programme of activities and these include Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 13 dance classes, support out in the community, music groups and exercise classes. One service user does not attend day service but has an individual activities programme and this is based on the service users individual choice, this can involved ball games in the home, trips out into the local community or shopping trips. The service users at the home are encouraged to be part of the local community and regularly go out shopping, or go out on trips to pubs and cafes. On the day of the visit 2 of the service users were out at day service, another service user went out shopping, one went bowling and one was supported by an outside organisation to do individual activities of his choice. The home has a visiting policy and family and friends are welcome at any time. Service users are encouraged and supported to maintain family links and all of the service users have family involvement, this ranges from the exchange of cards, gifts and regular telephone calls to some of the service user going out to visit relatives or to have day and weekend stays with family. Daily routines in the home promote service users independence as much as possible and they are supported to undertake routine tasks around the home service users are involved in the day to day running of the home as much as there abilities allow. Staff were seen to treat service users with dignity and respect throughout the visit and staff were observed knocking on service users doors before entering and seeking permission for them to enter their rooms. Mail is given to service users unopened and staff support them with their mail. Service users are able to access all areas of the home and are able to choose if they wish to be alone in their rooms or be in the company of other service users and staff. There is a four week rolling menu, which is changed seasonally and takes into account the likes and dislikes of individuals as well as nutritional needs. Breakfast is normally cereals and toast, lunch is normally a snack type meal and the main meal of the day is in the evening. We saw staff supporting residents with lunch and service users helped as much as possible with the preparation of their lunch. Service users told us that the food is good and that they enjoy helping out at meal times. Staff at the home cook meals and we were told that if the main meal is not to service users liking then an alternative would be provided. We saw records of food prepared at the home and this showed that service users have a choice. The manager told us that they try to arrange a take away at least once per week and we saw staff supporting service users with their lunch. Service users told us that the food was good. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users receive personal support in the way they prefer and their physical, emotional and health needs are met. The homes policies with regard to medication are confusing in places and do not provide clear guidance for staff and protection for service users. EVIDENCE: Care plans for individual service users gave information on personal care needs and this gave staff information on what support service users required in the mornings and evenings and also information on individuals personal care skills so that staff could offer the correct type of support. Some of the service users need very little support with thier personal care needs and support for these service users is normally encouragement and verbal prompts. Other service users need more support and care plans gave staff information on what support was required and also how the service user liked this support to be given. Those members of the staff team who we spoke with told us that they Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 15 are flexible around the times when service users want their personal support and there are no set routines. All of the service users have a health section in their care plans and all are registered with the same local GP surgery but have different GPs. One service user told us that he had been to see the doctor on the morning of our visit and he said that staff supported him but he was able to talk to the doctor himself. Arrangements are in place for dental checks at a local NHS dentist, and sight checks are carried out by a local optician. Service users and staff are supported by the local learning disability team and access to all other relevant health care professionals is arranged through GP referral. Staff at the home monitor service users health and support service users to access appropriate healthcare professionals and to attend any appointments. We looked at the medication procedures at the home and there are clear procedures in place for the receipt, storage and administration of medication. All staff at the home has undertaken training in medication administration procedures. We looked at the Medication Administration Records (MAR) and these were clearly completed by staff and there were no gaps. We also looked at the homes medication policy, however this gave some conflicting information and did not provide clear guidance for staff; for example there was information that stated that the manager was allowed to buy stock medication for when required medication for service users, but in another part of the policy it stated that only medication prescribed by the GP for individual service users could be kept at the home. We spoke with the manager of the service who agreed that there was a need to update and amend the medication policy at the home. None of the service users at the home self medicates and at present there are no controlled drugs kept at the home. However the manager was reminded that should there be a need for any controlled drugs to be held at the home, they must be stored in a proper Controlled Drugs Cupboard. In brief, the requirements for CD storage are: • • • • Metal cupboard of specified gauge Specified double locking mechanism Fixed to a solid wall or a wall that has a steel plate mounted behind it Fixed with either Rawl or Rag bolts The Misuse of Drugs (Safe Custody) Regulations 1973 gives full details and suppliers of CD cabinets can confirm that a cupboard meets the legal requirements. We recommend that care homes request formal confirmation when purchasing a CD cabinet. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are protected by a clear and accessible complaints procedure and the homes policies and procedures help protect service users from any form of abuse. EVIDENCE: The home has a clear complaints procedure and this includes timescales for the complaint to be addressed. All service users have a copy of the complaints procedure and one of the service users we spoke with told us that if he had any concerns he would talk to his key worker or the manager, he told us that he was sure that any concerns would be sorted out. Another service user who we spoke with was no able to understand the procedure to be followed. Staff members we spoke to were aware of the complaints procedure and said that they would support any service user to make a compliant if they wished. The home keeps clear records of any complaints made and also records responses. There AQAA told us that there had been one complaint in the past 12 months and this was confirmed by the manager and we saw that this had been appropriately recorded. Staff receive training in the protection of vulnerable adults and those spoken to said that they would talk to the manager if they had any concerns, they were aware that they could go above the manager if they felt that this was appropriate and knew that social services would take the lead in any adult Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 17 protection issues. The home had one incident where a referral had been made to the safeguarding team at Southampton Social services and this had been appropriately reported and was dealt with in line with laid down procedures. The manager of the home is appointee for one service user and she holds bankcards for this service user to enable her to draw out money on the service user’s behalf. Only the manager is aware of individual pin numbers and these are kept secure. We discussed the issue of the manager keeping bankcards and pin numbers and pointed out the potential problems that could arise. The manager understands that this is not an ideal solution and as such has contacted the service users placing authority who are organising a money management review. Two of the service users at the home keep small amounts of spending money in there own personal wallet and they take responsibility for this. The home keeps small amounts of personal spending money on behalf of some of the service users and records are kept of all transactions and this provides a clear audit trail. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is reasonably well maintained, however the system for reporting and rectifying any defects at the home does not provide evidence that defects are identified and rectified in a timely manner. The home was generally clean and free from offensive odours and provided a homely environment for service users and staff however some areas of the home would benefit from decoration. EVIDENCE: The home is laid out over 3 floors; the ground floor consists of a Kitchen/diner, utility rooms, separate WC, lounge, separate dining room, and 1 ensuite bedroom. The first floor has 3 bedrooms, 2 bathrooms and an office/sleep in room. The second floor has 2 bedrooms and shower room with WC. The shower room on the 2nd floor was seen to have mouldy grouting and this needs to be thoroughly cleaned as this could present a health hazard to anyone using Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 19 it. There were new carpets on the stairs and in the lounge area and the manager informed us that one of the service user’s bedrooms had been decorated. We found the communal areas bright and airy but paintwork was looking tired and some areas of the home would benefit from re-decoration. WCs were seen to have soap dispensers and paper towels. Staff carry out weekly health and safety checks of the home and record any defects on the weekly check list, this is then passed to the manager who reports any problems to the provider verbally. There was no record of when defects have been reported or when they have been rectified. The system currently used at the home do not provide evidence that defects are identified and rectified in a timely manner. The home has a utility room, away from areas where food is prepared, stored, cooked or eaten and this contains a domestic washing machine, which is able to wash clothing at appropriate temperatures and a domestic tumble drier. Staff at the home support service users with their laundry and appropriate protective clothing is available. There was no set procedure for the washing of any soiled items, which would help to control any infection issues and this was discussed with the homes manager who said that she would ensure that clear procedures were laid down to provide guidance and advice for staff. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff employed at the home have the competencies and qualifications required to meet service user’s needs. Service users are protected by the homes staff recruitment procedures and service users are supported by trained staff, however some staff require refresher training to update their skills. EVIDENCE: The homes staff rota showed that there are a minimum of 2 staff members on duty between 0730 and 2200 and at night there is one member of staff on duty who sleeps in. Service users and staff who we spoke with told us that they felt that staffing levels were about right, staff said that extra staff are used to provide additional support if service users have specific plans to go out, the staff rota showed that this level of staffing is consistent and that bank staff are used to cover for sickness and holidays. The registered manager is employed as part of the normal staff rota but is also provided with dedicated management hours. The home does not employ any domestic staff or a maintenance man. Service users spoken to said that staff were very friendly Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 21 and that they liked all of the staff. The notice board at the home has photos of the staff members who are on duty for each day and service users told us that they liked to see who would be supporting them. The home employs a total of 6 care staff, including the manger and there are 2 regular bank staff who work at the home. The manager told us that 2 staff hold NVQ3, 2 staff are in the process of obtaining NVQ3 and 1 staff member is just starting NVQ2. The home has a stable staff team and recruitment records were seen for 2 staff members including the most recently employed staff member. Both files contained application form, references x 2, interview notes, passport, photograph, and National Insurance Number, birth certificate and CRB/POVA checks. The completed AQAA told us that the home has a robust recruitment procedure and this was confirmed by the records we saw on the day of the visit. Staff training records were looked at and we saw that staff had received training in first aid, food hygiene, manual handling, Protection of Vulnerable Adults, medication, COSHH, moving and handling, managing challenging behaviour, infection control and health and safety. Staff files contained training certificates; however some of these certificates were out of date. The manager told us that she was in the process of organising refresher training for staff. The training file for the newest member of staff had the skills for care induction procedure, which had been completed and staff told us that since the new owner had taken over more training was being made available. The completed AQAA told us that staff receives regular training from an outside training organisation and that the staff rota allows staff to attend training sessions when arranged. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is registered with the Care Quality Commission and is experienced and competent to run the home. Service users, relatives and other interested parties are consulted about the running of the home and there are policies and procedures in place regarding quality assurance. The health safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager has been registered to manage the home since 2005 and is due to complete her Registered Managers Award in September 2009. She has NVQ4 in care and he has the skills and experience to effectively manage the Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 23 home. Staff who we spoke with told us that the manager was very approachable. We looked at quality assurance questionnaire that had been sent out by the home and these were sent to all of the service users. The manager told us that she had not yet sent out questionnaires to relatives, staff or health care professionals but she said that these would be sent out shortly. Responses from the completed service user questionnaires were positive about the home and all indicated that they were happy at the home. Staff told us that there are regular staff meetings and that keyworkers meet with service users weekly and feedback any issues that may arise at the staff meeting. The home sends us information about any incidents in the home and the provider carries out monthly visits in accordance with Regulation 26 of the care home regulations. We looked at the homes fire log book and this showed us that all relevant training and testing has been carried out. We looked at the homes Gas safety certificate and the certificate for the homes fixed electrical wiring and these were both in date as was the certificate of insurance for public liability. Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Version 5.2 Page 25 Thornbury House DS0000073287.V376153.R01.S.doc N/A 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 YA20 Regulation 13 Requirement Timescale for action 30/08/09 2 YA20 13 3 YA35 18 The homes medication policy must provide staff with clear information regarding medication procedures at the home. This will ensure that staff have the information and guidance they needs and this will also provide protection for service users. The registered person must 30/09/09 ensure that any controlled drugs that are held at the home are stored in a proper Controlled Drugs Cupboard the meets the legal requirements laid down The Misuse of Drugs (Safe Custody) Regulations 1973. This will ensure that the home complies with the law. The registered person must 30/09/09 ensure that staff receive training appropriate to the work they are to perform this will ensure that service users are appropriately supported Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thornbury House DS0000073287.V376153.R01.S.doc Version 5.2 Page 27 Care Quality Commission The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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