Inspection on 15/06/06 for Thistle Hill Hall

This inspection was carried out on 15th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Thistle Hill Hall 12/08/09

Thistle Hill Hall 24/05/07

Similar services:

Trevayler Residential Care Home

Thornham Grove

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

Brain Injury Services, 51 The Drive

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

CARE HOME ADULTS 18-65 Thistle Hill Hall Greenacres Debdale Lane Mansfield Woodhouse Mansfield Nottinghamshire NG19 7EZ Lead Inspector Rob Cooper Key Unannounced Inspection 15th June 2006 10:00 Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 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 Thistle Hill Hall DS0000063549.V299285.R02.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thistle Hill Hall Address 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) Greenacres Debdale Lane Mansfield Woodhouse Mansfield Nottinghamshire NG19 7EZ 01623 655100 www.debdalecare.co.uk Debdale Care Limited Mrs Susan Lepori Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named Service User to be admitted above the age of 65. Service User shall be in Category MD. Date of last inspection None – This is the first Inspection Brief Description of the Service: Thistle Hill Hall is a Grade II listed building, which provides residential care for adults who have enduring mental health problems. The accommodation is situated on two floors with the upper floor being accessed via stairs or a passenger lift. The accommodation is spacious with high quality fixtures and fittings, and is tastefully decorated throughout, while still incorporating many of the original features from the building’s past. Outside there are ample grounds much laid to lawn, although an abundance of shrubs and trees add to the privacy of the house. To the front of the building is a small car park for staff and visitors. All bedrooms have en-suite facilities, and there are two training kitchenettes as well as a central kitchen and dining room. On site, there is a gymnasium, as well as a hobbies/games room, with table tennis, pool and a variety of tabletop games and activities. Thistle Hill Hall has two lounges, a visitor’s room, and ample bathrooms and toilets in addition to the en-suite facilities. These bathrooms are spacious, and a person with mobility difficulties could be accommodated. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took place through the middle of the day lasting approximately four hours, with one Inspector present. The methodology used was to visually inspect parts of the premises, talk with five residents, four members of staff, and case track three residents. Case tracking involves talking to residents and looking at a range of care records, to make a judgement about the quality of care that residents are receiving. In addition two relatives were spoken with, to gain their views of Thistle Hill Hall. This is a new service, and this was the first Inspection. The impression is of a well-run service that has made an excellent start. The entry fees for Thistle Hill Hall start at £172 per day. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 6 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 Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12&5 The quality outcome in this area is: Excellent Prospective residents have the information they need to make an informed choice about living at Thistle Hill Hall. Prospective residents’ individual needs and aspirations are assessed. Each resident has an individual written copy of the terms and conditions of residence. EVIDENCE: Both the Statement of purpose and Service User Guide were seen, and both of these documents contained all of the information required by Care Homes Regulations. The information was presented in a user-friendly format with plenty of photographs to illustrate the information. In addition all of this information is available on the Thistle Hill Hall website. Three resident’s files were seen and each one contained comprehensive assessment material, the assessments were both pre-admission assessments (by an appropriate health or social care professional) together with assessments carried out in-house by Thistle Hill Hall staff. All three files contained a copy of the terms and conditions of residence. During the Inspection five residents were spoken with, and two when asked said that they had a copy of the terms and conditions of residence, while four residents said that they had a copy of the service user guide – it was in their bedroom when they had moved in, as part of a ‘welcome pack’. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 9 & 10 The quality outcome in this area is: Good Residents know that their assessed and changing needs and personal goals are reflected in their individual plan. Residents at Thistle Hill Hall make decisions about their lives with assistance as needed. Residents are consulted on, and participate in all aspects of life within Thistle Hill Hall. Residents are supported to take risks as part of an independent lifestyle. Residents know that information about them is handled appropriately, and that their confidences are kept. EVIDENCE: Each of the three resident’s files that were seen had a clear individual plan of care, with care plans and information laid out in a logical sequence. Further inspection showed that the care plans were under review in a timely manner – Care Homes Regulations indicate that a minimum of six monthly review of care plans is appropriate, although care plans at Thistle Hill Hall were seen to be being reviewed much more frequently. There was also evidence that residents had seen their plan of care and had signed certain documents to show their consent/agreement. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 9 Three residents were asked about decision-making, and each one said they felt they had control over the day-to-day aspects of their lives. The staff were seen by one resident as being there to offer support not ‘take control’. There are regular residents meetings (every Tuesday and Thursday morning) and the minutes were seen, which showed residents are involved in the decision making process within Thistle Hill Hall. There are two kitchenettes for the use of residents, where they can make snacks and do their washing. During the Inspection one resident was seen to be sorting their washing, discussions indicated that the central laundry was used just for washing bedding, towels and tablecloths, while residents were encouraged and facilitated to wash personal items themselves. Two residents were asked about washing, and both said that they were quite happy with the laundry arrangements. Each of the three files that were seen contained risk assessments, which had been written on an individual basis, and were relevant to the risks pertaining to each individual resident. One resident was asked about risk taking, and said that they were happy with the situation: “If I want to do something, they (the staff) talk to me about it first, and don’t just say no!” Information about residents was seen to be stored securely. The residents have mental health problems, which does mean that some residents are very sensitive about their personal information. There was clear evidence that staff were aware of this, and staff were seen to be talking to residents directly, rather than talking about them. As already identified there was evidence within the personal files that residents had seen the care plans, and they had signed to say that they agreed with the plans that were in place. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 15 16 & 17 The quality outcome in this area is: Excellent Residents at Thistle Hill Hall have opportunities for personal development. Residents are able to take part in age, peer and culturally appropriate activities at Thistle Hill Hall. Residents are part of the local community. Residents have appropriate personal and family relationships. Resident’s rights and responsibilities are recognised in their daily lives. Residents at Thistle Hill Hall are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: There are a number of on site facilities to assist residents in the development of personal skills. As well as the two kitchenettes, where social skills can be taught, and developed, there is a fully equipped gymnasium, and a craft room is being developed. In addition some residents attend Gamelea and Huntstone Grange – which are two local day centres, where crafts and activities are arranged for the residents. There is also an activities room equipped with table tennis, table football, and computers (although these do not have internet access – internet access is available in the office in a supervised session.) Thistle Hill Hall currently has pet rats, a rabbit, and cage birds, and until fairly recently a dog. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 11 Three residents were asked about activities at Thistle Hill Hall, and each person spoke positively about trips out in the minibus, shopping in town, and going to local discos and entertainment. Thistle Hill Hall is physically isolated from it’s immediate neighbours, in that it stands on a hill, in extensive grounds away from local housing. However residents do use local community facilities both within Mansfield Woodhouse and the wider Mansfield area. Two residents talked about shopping at the local shop for cigarettes and sweets, and going into Mansfield shopping, and to the cinema. During the Inspection some relatives were spoken with, they live some distance from Thistle Hill Hall, and the staff had picked them up that morning in the minibus and brought them to see their relative. On occasions their relative is also brought down by the staff to visit them at their home. Two residents were asked about relatives visiting, and both said that staff had taken them to see relatives who do not live locally. One resident said that: “they used the telephone in the office to ring their family, and that it was good, as the phone in the office didn’t cost them anything.” The relatives who were visiting Thistle Hill Hall spoke very positively about their experiences, and said that the staff were very helpful, in arranging visits. All three of the resident’s files that were seen contained a behavioural contract. This identified behaviour that was acceptable, and behaviour that was not – a setting of the ground rules. This contract had been discussed in a resident’s meeting, and one resident said they had contributed to it’s content. Staff were seen to be interacting with residents during the Inspection, and this was done in a polite and respectful manner, with staff seen to be knocking on bedroom doors before entering (even on rooms that were known to be empty). Two residents when asked said that they thought the staff treated them well, and they were well ‘looked after.’ The dining room was seen, and this was tastefully decorated with matching maroon tablecloths and napkins. All of the residents were asked about the food and everyone said it was “really good.” The main meals are cooked centrally, and the menus showed that there was a nutritionally balanced diet, with plenty of choice and variety. During the Inspection a number of residents were ‘snacking’ on bacon & egg cobs cooked in the main kitchen by the staff – these looked and smelt very appetising, and two residents who were asked said they were very nice. In addition to the meals cooked centrally a number of food items are put into refrigerators in the training kitchenettes, so that if a resident wakes in the night and is hungry, there is food available 24 hours a day. All food placed in to the refrigerators in this way, was seen to be dated, and there was a clear rotation of stock in place through the kitchen and kitchenettes. All of the records within the kitchen, when checked were found to be correct and complete – food temperature probes, refrigerator and freezer temperatures, and the choices of meals made by residents. The relatives who were visiting had been given sandwiches when they arrived, and said that these were “very nice indeed.” Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 & 20 The quality outcome in this area is: Good Residents at Thistle Hill Hall receive personal support in the way they prefer and require. Resident’s physical and emotional health needs are met at Thistle Hill Hall. Residents at Thistle Hill Hall are protected by the home’s policies and procedures for dealing with medication. EVIDENCE: All three personal files that were seen identified personal care delivery within them. Discussions with staff about the different ways in which personal support is delivered, showed that there was a clear understanding of differing needs, choices and wishes. Two residents were asked about their personal support: one said they were quite happy, and that they saw to their own needs. A staff member explained that the ‘staff approach’ was of a ‘hands off’ and distance approach to encouraging the individual to make positive choices around personal hygiene, rather than a more directive approach. This appeared to be working well, and the resident seemed quite happy with the arrangement, telling me: “I sometimes forget things, but the staff will just remind me.” The second resident said they had a shower in their bedroom, Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 13 which was good, and they could ‘ have a bath if they wanted one.’ All three files had clear documentation around the health needs of the residents. Some residents had required hospital treatment since they had been living at Thistle Hill Hall, and this was well documented. One resident told me about their experiences at the local hospital, and how the staff had supported them while they were there, the resident’s position being that the staff had been very helpful in talking to the doctors and nurses, and sorting out the medical problem. Medication at Thistle Hill Hall is arranged through Boots (the chemists) and is a Monitored Dosage System – This is where Boots prepare medication into measured dosages on a card with a push out section – known as a blister pack. Currently no residents self-medicate, and two residents who were asked said that they were quite happy with the way that medication was arranged and organised. Medication was seen to be stored securely and there were clear and comprehensive records relating to medication coming into and leaving the premises. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality outcome in this area is: Excellent Residents at Thistle Hill Hall feel that their views are listened to and acted upon. Residents are protected from abuse, neglect and self-harm. Residents are protected from abuse, neglect and self-harm. EVIDENCE: Four residents were asked if they thought they were listened to, and whether their views were acted upon. Two residents talked about the residents meetings, which are held twice every week – the most recent one had been that morning. Both residents said that at the meeting the staff would tell residents what was happening – any new residents coming or staff changes, and would talk about activities too. Both residents also said that they had a chance to comment on things like: the food, the activities, outings etc. An example was a trip to the seaside, which one resident had said they wanted to go on. This had been arranged for the following weekend. The other two residents said they felt listened to and gave examples to support this. Staff training records were seen and these showed that the majority of the staff had received training in Adult abuse and the Protection of Vulnerable Adults (POVA), and that further training had been booked in this area. Three residents were asked whether they felt safe living at Thistle Hill Hall, and each one said they did. There is a team approach to key working, which means that there is not only continuity, but also a sharing of responsibilities which is an open handed approach. Some of the residents have the potential to self-harm, and this was identified in individual resident’s files – with a care plan and risk assessment to manage the risk and direct staff in how to work with a person who self-harms. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 26 27 & 30 The quality outcome in this area is: Excellent Residents at Thistle Hill Hall live in a homely, comfortable and safe environment. Resident’s bedrooms promote their independence. Resident’s toilets and bathrooms provide sufficient privacy and meet their individual needs. Thistle Hill Hall is clean and hygienic. EVIDENCE: A partial Inspection of the premises showed that it had been decorated and furnished to a very high standard. The building despite it’s size remained homely, and was extremely comfortable and no obvious hazards were seen. Three residents were asked about the building and each one said it was very nice, and they liked living there. A number of bedrooms were seen, each one has en-suite facilities, with a minimum of a toilet and washbasin, while some bedrooms have an additional en-suite shower too. Bedrooms are well furnished, and tastefully decorated, with residents having personalised their bedrooms. All of the residents who were spoken with said they liked their bedrooms, and the en-suite facilities help to promote independence. In addition to the ensuite facilities within the bedrooms there are a number of bathrooms and a Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 16 toilets throughout the building, so that a resident can choose to either bathe or shower. The bathrooms are spacious and well decorated. Privacy is not a problem, as residents can access their own en-suite facilities or use one of the communal ones, all of which are fitted with a lock. Throughout the building there was a fresh ‘airy’ feel, and staff were seen to be cleaning areas of the building. Cleaning cupboards were well stocked with a good variety and range of cleaning materials. Two residents were asked about the cleanliness of the building, and both said that it was fine. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 & 36 The quality outcome in this area is: Excellent Residents at Thistle Hill Hall are supported by competent and qualified staff. Residents are supported by an effective team. Residents are supported and protected by Thistle Hill Hall’s recruitment policies and practices. Resident’s joint and individual needs are being met by an appropriately trained staff team. Residents benefit from a well supported and supervised staff team. EVIDENCE: Two staff files were seen, together with staff training records. These showed that new staff had undergone an intensive Induction programme, and that there was an ongoing staff training programme in place. Three members of staff were asked about their experiences of working at Thistle Hill Hall, and each one said they had had an Induction, and had undertaken a wide variety of other training – two had attended Protection of Vulnerable Adults training and the third was due to attend a course in the coming weeks. National Vocational Qualification (NVQ) training was available to staff, and one person had almost completed their level II in care, while a second was close to finishing their level III. Senior staff are experienced and qualified in the care Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 18 of people who have mental health problems, and this was evidenced through two Manager’s personal files, and curriculum vitae’s. Discussions with members of staff and a review of documentation clearly evidenced that Thistle Hill Hall takes a team approach to its work with residents. Key working is done by a team of staff rather than individuals, and support for staff members is arranged along similar lines. Two staff files were seen and these contained evidence of comprehensive measures taken to screen staff – POVA First, and Criminal Records Bureau checks, together with application forms and two written references, which all evidence that Thistle Hill Halls recruitment policies and practices do protect residents. The staff training records evidenced that there is an ongoing staff training programme, and all staff are being involved in job and role specific training. Discussions with staff members confirmed that there is a good quality and variety of training on offer to staff. Staff records show that all members of staff have a regular one to one supervision session with a senior member of staff. All three members of staff who were spoken with said they felt very well supported and supervised, and their were very good lines of communication through the team. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 & 43 The quality outcome in this area is: Excellent Residents at Thistle Hill Hall benefit from a well run home. Residents are confident that their views underpin self –monitoring, review and development at Thistle Hill Hall. The health, safety and welfare of residents are promoted and protected at Thistle Hill Hall. Residents benefit from competent and accountable management of the service. EVIDENCE: The Senior Management at Thistle Hill Hall are suitably qualified and experienced. The Registered Manager’s personal file was seen together with a range of policies and procedures, which evidenced that Thistle Hill Hall is a well-run care home. Residents meetings take place on a monthly basis, with the minutes for the last four meetings (April to June) seen. The minutes show that residents are able to, and do comment on aspects of the running of Thistle Hill Hall, and their voice is heard. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 20 In addition to regular residents meetings Thistle Hill Hall employs a recognised Quality Assurance system to monitor it’s in-house activity, and strive for improvement. A range of Health & Safety records were seen and these were found to be comprehensive and complete. During the Inspection the maintenance staff were testing the smoke detectors throughout the building. Records seen and checked included: Fire records, Control of Substances Hazardous to Health (COSHH), The Gas Safety certificate, Water testing (for Legionella and temperature), and Electrical safety checks. The Responsible Individual was present at Thistle Hill Hall during the Inspection, and there was clear evidence of an open an inclusive management structure. Regulation 26 visits (Visits by the Responsible Individual to the home on a monthly basis to check that the residents are fit and well, and that the home is being run properly) are happening on a monthly basis and reports of the visits are being sent to the Commission for Social Care Inspection for information and monitoring. Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 21 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 4 2 4 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 4 27 4 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 4 X X 4 3 Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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. Refer to Standard Good Practice Recommendations Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thistle Hill Hall DS0000063549.V299285.R02.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!