Inspection on 01/06/06 for Thistlegate House

This inspection was carried out on 1st June 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Thistlegate House 25/03/09

Thistlegate House 13/02/08

Thistlegate House 20/08/07

Thistlegate House 13/02/07

Thistlegate House 30/01/06

Thistlegate House 29/06/05

Thistlegate House 01/10/04

Thistlegate House 16/06/04

Thistlegate House 05/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Thistlegate House Axminster Road Charmouth Dorset DT6 6BY Lead Inspector Marion Hurley Key Announced Inspection 10:00 1 & 2nd June 2006 st 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 DS0000026880.V291418.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000026880.V291418.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thistlegate House Address Axminster Road Charmouth Dorset DT6 6BY 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) 01297 560569 01297 560569 Mr John A Corney Mrs June P Webb Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places DS0000026880.V291418.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One of the following rooms may be used as a double at any one time: 4, 15, 17, 27, 28, or 31 One named person (as known to CSCI) in the category DE(E) may be accommodated to receive care. 30th January 2006 Date of last inspection Brief Description of the Service: Mr J Corney and Mrs J Webb have owned and managed Thistlegate House since 1994. Thistlegate House is an elegant Grade 11 listed property standing within four acres of grounds. The landscaped gardens comprise many fine trees, lawns, terraces and walkways and there are commanding views across Lyme Bay. Attractive garden furniture and potted plants compliment the paved patio area directly outside the lounge, which provides a relaxing place for residents and visitors to enjoy. Thistlegate House is situated near to the seaside village of Charmouth and is approximately two miles from the coastal resort of Lyme Regis. The accommodation comprises a total of 17 bedrooms, mainly singles, spread over the ground and first floor. There is a large lounge and a dining room and five bathrooms plus additional WCs; one single and one double-sized bedroom have an en-suite WC facility. There is no passenger lift in the home. For service users with limited mobility access to first and lower floor bedrooms is achieved by the use of a stairmatic chair with staff assistance. The home is registered to provide personal care only, for older persons with a variety of care needs. Access to health services is via GP’s and Community Nurses. Dental and optical and chiropody services can be arranged as required. Fees range from £417-£600 per week. Current Inspection reports are available and the home has an attractive colour brochure providing information on the services and facilities available. Thistlegate House advertisers in local publications and hopes to develop a web site in the future. DS0000026880.V291418.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over seven hours. Fifteen residents were accommodated in the home on the day of the inspection. Residents and staff and the Registered Providers were spoken with during the inspection. The Registered providers were available throughout the inspection and had prepared for the inspection. Records were examined, including the care records of three residents, three staff files and records relating to health and safety procedures in the home. A tour of the home and grounds was carried out at this inspection and included the laundry, kitchen, dining room, lounge and resident’s bedrooms. The inspector was grateful for the time and support provided by the residents, staff and Registered providers on the day of this inspection. A total of 10 “Have Your say” comment cards were received from residents, 6 from relatives and friends and 4 were completed by professionals. Comments included “ she is very well looked after”, “well run happy place with excellent care and concerns for residents” “ the care provided is excellent.” What the service does well: Thistlegate House is a listed property with associated constraints however despite this the overall standard of the facilities is good. Residents at Thistlegate House are pleased with the home and the standards of care. They like the homeliness of Thistlegate and appreciate the opportunities they have to make decisions and choices in their daily lives. Residents and visitors spoken with feel that staff deliver a consistently high standard of care. Residents were most complimentary of staff, saying that their care needs were “always well met” and they were “thoughtful, good natured and kind.” New staff are appropriately recruited and recent recruits have complimented the strong team of established staff, many of whom have worked at Thistlegate for several years. Residents in the home have risk assessments to help determine their safety. All accidents, injuries and incidents are recorded and reported to the statutory bodies. Fire safety notices are posted in relevant places around the home. DS0000026880.V291418.R01.S.doc Version 5.1 Page 6 The quality of the meals is good with locally sourced products being obtained regularly. The chef sets high standards and provides an interesting and well balanced menu, which is appreciated by all the residents. Visitors are always welcome and the residents have opportunities to see their relatives and friends in private. The residents and staff spoken with felt that there were no significant improvements necessary. They were all satisfied with the service and their work at the home. 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. DS0000026880.V291418.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000026880.V291418.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality in this outcome group is good. This judgement has been made using available evidence including a visit to the Home. Residents moving to Thistlegate are appropriately assessed prior to their admission to ensure that their needs can be fully met through the services and facilities and staffing arrangements at Thistlegate House. If residents are referred through Care Management process, the registered providers obtain a summary of the care management assessment and a copy of the Care Plan produced for care management purposes which provides additional information ensuring the home can meet the person’s needs. EVIDENCE: Since the last inspection four people have moved to Thistlegate House. Two records were examined and both contained assessments. These clearly identified the resident’s needs and abilities. In each case their preferred daily routines were described with specific references to morning and evening times. DS0000026880.V291418.R01.S.doc Version 5.1 Page 9 The reason for admission was recorded and this is significant when staff are establishing a rapport with the new resident. Good details were noted which referred to the type of bed linen residents liked i.e. blankets or duvet, whether they wanted their widows open or closed at night e.g. “ likes to have their window open day and night.” Where possible the Registered Providers ask the resident to sign their own Care Plan, however, some residents do not wish to be involved and in these situations a relative or friend is invited to sign on the resident’s behalf to acknowledge agreement with the details in the care plan. The inspector took the opportunity of discussing with one resident their perception of the admission process and from their recollections they thought, “ it went quite smoothly, everyone was very kind.” A visitor also confirmed the arrangements for the admission had been planned and staff were ready and briefed on their arrival and the bedroom had been redecorated and was welcoming. Prospective residents receive written confirmation prior to moving into the home that Thistlegate House have the services, facilities and staffing arrangements to meet their individual needs. Contracts and Terms and Conditions are issued stating the fees and any extra charges for items such as personal toiletries, newspapers, hairdressing etc. Standard 6 does not apply to Thistlegate House. DS0000026880.V291418.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 The quality for this outcome is adequate. This judgement has been made using available evidence including a visit to the home. Residents’ health and personal care needs are met, as demonstrated within care plans. Medication was appropriately distributed to meet resident’s needs. EVIDENCE: Four sets of residents’ records and care plans were case tracked. All the basic information, concerning each resident was found to be in the files examined. Pre admission assessments and or care management assessments/plans were in the files and risk assessments. Where necessary the assessments gave clear instructions to the staff e.g. “be calm and offer comfort and support” this referred to assisting a resident who required specific aids to help access areas of the home and garden. The Registered providers and staff encourage and support residents to access all health and remedial services and the residents’ records indicated regular DS0000026880.V291418.R01.S.doc Version 5.1 Page 11 appointments and community visits were undertaken. Details of outcomes of such appointments were record in the residents’ individual daily records and were highlighted to ensure all staff read the significant entry. Thistelgate House and the residents are well supported by the local GPs and District nurses. A chiropodist routinely visits every six weeks and Specialist nurses, when required, e.g. community psychiatric nurses, palliative care nurses. All the residents’ care plans and daily records which were read provided a good picture of each resident’s abilities and how their needs were met, however, not all the records indicated regular and formal reviews were being conducted though the daily records reflected any changes in the resident’s plan of care. The registered providers and staff verbally confirmed that the residents’ plan of care was continually and informally reviewed and adjusted as and when required. These adjustments need to be clearly documented to ensure the provision of care is maintained. All medication and the method of distributing it to residents were examined. Thistlegate House has medication policies and procedures, which the records demonstrated were being implemented. Boots the Chemist undertake six monthly reviews checking the safe handling, storage and adminstation of all medication. The Primary Care Trust conducts regular inspections. The last inspection was undertaken on 06:02:06 and the report stated, “mar sheets and storage excellent.” (MAR =Medication Administration Record). Six staff are due to commence the Boots accredited training on July 18th 2006. All medication was clearly labelled and there were no surplus supplies. Each shift has one identified member of staff who is the “key holder”. This person is designated responsible for administering medication for that shift. Two residents were spoken with about life in the home. Both said independently that staff were very good at listening to their views and would always try “their hardest to meet my wishes”. One person said that they “felt safe in the home” and “well looked after”. Written comments received included “the care provided is excellent and the staff are kind and caring” “ excellent care and concern for the residents.” DS0000026880.V291418.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15. The quality for this outcome is good. This judgement has been made using available evidence including a visit to the home. The registered providers and staff at Thistlegate House respect the residents preferred lifestyles. Residents are able to receive visitors and to exercise choice and control over their lives. Residents are given a wholesome and appealing diet in pleasant surroundings, which they are able to enjoy. EVIDENCE: One resident was asked about leisure time in the home. They said that events included visiting entertainers, occasional trips out and other things such as watching historical videos. The resident also said that staff sometimes take residents out for walks round the attractive gardens and grounds. The resident said that she felt her needs were met and that staff respected her confidences and always treated her with respect and dignity and “there was no one she didn’t get along with” “all the girls are good”. Two other residents particularly said how good it was that they could go to bed and get up at times of their own choosing and within reason could choose their DS0000026880.V291418.R01.S.doc Version 5.1 Page 13 own bath times. One visitor commented how nice it was that the television was used very selectively and “not just left on”. One member of staff has a special interest in leisure activities and instigates a variety of different opportunities for the residents whether that is enjoying a video and then discussing it or having a manicure, receiving help with knitting or joining in the most recent event of an Easter Parade. Several residents confirmed they preferred to stay in their rooms listening to music or quietly reading. A hairdresser visits the home regularly and many of the residents take advantage of this with the occasion becoming quite a social event. The hairdresser was visiting on the day of this inspection and the inspector observed and overheard much laughter and banter throughout the morning. Residents can go shopping in the local town if they wish, although relatives would need to take them, as it is some distance away. Ministers visit the home to provide a Sunday service / communion and at the time of a general or local election residents are provided with postal votes and supported in this process by the Registered providers. The registered providers enjoy special occasions and always offer extra hospitality on a resident’s birthday or special occasion. Relatives and friends of residents are able to visit at any time and residents can always be seen in private. Several residents when asked stated that staff always knock on their bedroom doors before entering. Most of the residents spoken with said their meals were “excellent”, “very good”, “most enjoyable”, however, others felt they were “okay but lacked variety sometimes.” On average six residents regularly use the dining room while others prefer to have their meals in their bedrooms. The catering at Thistlegate is a good overall standard with fresh locally sourced products used when possible. Residents are always offered at least two daily choices. Each morning the chef informs the care staff what the menu choices are and the staff during the morning routine with the individual residents discuss the choices and then advise the chef. Homemade soup is available daily and this is always popular. From discussions with the Registered providers and the chef there is an obvious sense of pride in the quality of the meals prepared for the residents. All records relating to food hygiene and health and safety in the kitchen and in the preparation and handling of food were up to date and clear to read. All food stored in the cool larder or in the freezer or fridges was labelled. There is a separate menu book/diary for the main meal of the day and for the evening meal where all food consumed is recorded and a record also noted if any resident has chosen an alternative dish or is not sufficiently well to eat. Food is considered to be highly important and meal times considered a social occasion. Written comments received included “they make lovely soups”, “the cooking is the best.” “they look excellent.” DS0000026880.V291418.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. The quality for this outcome is good. This judgement has been made using available evidence including a visit to the home. The home has appropriate complaints policies and procedures, which ensure the residents needs and any concerns, are addressed. The protective policies and procedures provided by the home mean that residents are protected. EVIDENCE: Four residents were specifically asked if they felt confident to raise any complaints or concerns with the Registered providers and all independently said they would have no difficulties and felt “sure they would be listened to and either of the providers would sort things out”. The residents were very clear that they would “talk things through with any of the girls”. The Commission has not received any notice of complaints or concerns since the last inspection (January 2006). The Registered providers also stated that no one had discussed any significant concerns with them and the record of concerns/ complaint had not been used. Minor every day issues are dealt with immediately and reference if appropriate is made in the resident’s daily notes. A good practice recommendation is made that even though the residents have not recently made any formal complaints or raised concerns the more significant minor verbal issues should be logged in the complaints/ concerns DS0000026880.V291418.R01.S.doc Version 5.1 Page 15 book, along with the action taken to rectify these matters to the resident’s satisfaction. The home has an Adult Protection procedure that includes a whistle blowing policy. The Registered provider stated they would follow up all allegations and incidents and all actions would be recorded. The Registered provider said that all staff understood physical and verbal aggression by residents though this was very rare at Thistlgate House, however, there had been an incident when one resident became disorientated and physically tried to stop staff from supporting them and attempted to pull staff hair. All these details were logged and passed to the statutory agency for reference and professional advice in the management of this behaviour was sought and forthcoming and the matter was resolved. Written comments received included “on the rare occasion I may have to complain they will listen and help straight away” DS0000026880.V291418.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, & 26 The quality for this outcome is good. This judgement has been made using available evidence including a visit to the home. Thistlegate is well maintained throughout, providing residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the entire home and grounds, including the bedrooms of residents. The bedrooms are well laid out with good space provided for each resident. The bedroom doors are lockable and residents may choose to have their own key if they wish. Appropriate furniture is provided in the bedrooms. The communal lounge and separate dining room are attractive rooms furnished to a high standard offering residents and visitors a choice of places to sit quietly, meet with friends and family or enjoy the company of fellow residents. Outside the lounge is an attractive patio overlooking the gardens. Both residents and visitors enjoy this area. DS0000026880.V291418.R01.S.doc Version 5.1 Page 17 The home is generally clean and fresh however one bedroom had an unpleasant odour. The Registered providers are aware of this and with staff have tried to eradicate this problem. The odour does not permeate beyond the bedroom but needs to be resolved for the comfort of the resident. The laundry is done in two separate rooms. One room is outside the main building and this is where the heavy laundry is done e.g. bed linen, the other room in the basement caters for the personal laundry of residents. All the residents have their own laundry basket and all the clothes are labelled. There appeared to be an efficient and well-organised system. Residents were asked if they experienced any problems and all those asked said they did not and clothes got returned “nicely washed and ironed.” Two comment cards specifically referred to the cleanliness of the home one stating it “is always fresh and clean, perfect in this respect” and the other indicating that not all aspects of the bedrooms were leaned on a daily basis. No domestic /cleaning staff are employed at Thistlegate House and the Registered Providers may need to review this situation especially when occupancy/dependency levels are higher than at present. DS0000026880.V291418.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 The quality for this outcome is good. This judgement has been made using available evidence including a visit to the home. Sufficient care staff are provided within the home to meet residents’ needs. EVIDENCE: Staffing provided in the home was compared with the details provided by the Residential Forum. This showed that the home was meeting the recommended levels of staffing. The figures were calculated without the Registered Providers working time included, as recommended by the Residential Forum. Staff have chosen to work the same weekly shifts and this schedule was available for inspection. The twenty four hour day is divided into four shifts commencing at 07:30–13:30, 13:30-18:30, 18:30-22:00 and the night shift 22:00-07:30. Apart from the waking night worker all shifts have a minimum of two care staff and thirteen of the weekly shifts have three care staff working. No domestic staff are employed and though staff said they were busy they also said the work load was manageable and “we just get on with it”. This clearly is the case but as previously stated the Registered providers may need to review this especially with the increasing needs of residents. Please refer to comments in previous evidence. A chef is employed daily 07:30 – 14:30. The Registered providers are on site daily and are actively involved in the daily routines of caring for the residents. DS0000026880.V291418.R01.S.doc Version 5.1 Page 19 Of the 12 care staff employed 6 have NVQ level 2. therefore 50 of care staff have achieved NVQ 2 or above. The records of three staff were checked to ascertain if the Registered providers had obtained all relevant information about them. All three files were complete. All new staff receive a welcome letter and commence employment by completing a series of induction sessions, which includes working supernumerary for the first few shifts. The three staff on duty during the inspection were all spoken with and clearly enjoy their work with the residents. Observations throughout the day indicated the excellent rapport and understanding the staff have working with and enjoying the company of the residents. Residents spoke very highly of the staff and several independently stated “how good the girls were” “nothing seems to trouble them” “they’re really kind” “ she makes me laugh”. Written comments received included “the staff are very nice, always pleasant and ready to help in any way” “ the night staff are just as helpful as day staff” “the staff at Thistlegate are very kind” DS0000026880.V291418.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The quality for this outcome is adequate. This judgement has been made using available evidence including a visit to the home. The Registered Providers are experienced in both the business and daily running of Thistlegate House. They are both currently completing the required qualification NVQ level 4. EVIDENCE: The Registered Providers have managed Thistlegate House for many years and during this period have increased their own knowledge of the business and daily working and understanding of the working relationship required with the Commission for Social Care Inspection. They have the skills and ability to deliver good business planning, effective financial controls and provide an annual quality assurance system coupled with DS0000026880.V291418.R01.S.doc Version 5.1 Page 21 continual and informal self-monitoring. The home has the necessary insurance in place to enable it to fulfil any loss or liabilities. Thistlegate is a small family style home and feedback from residents, visitors and staff occurs daily. The Registered Providers are always available and have recently started to “manage the daily shifts” ensuring all the tasks are completed. The Registered Providers explained that the Home does not manage any of the residents’ financial matters though does hold small amounts of personal money for some and in other situations when money is needed to be spent on a resident’s behalf, the home will bear the cost and bill the relatives after each occasion that has occurred. Servicing records were checked and found to be up to date, bath hoists were serviced 03:02:06 and the stairmatic 10:01:06, fire alarms and equipment were tested and the certificate issued 03:05:06. Mandatory training is undertaken and all long term staff have completed Food Hygiene 2005 and First Aid, 2005. All staff have completed POVA training with the most recently recruited staff attending 11:05:06. Staff need to ensure their training in Infection Control and Manual Handling is current. The Registered Providers are aware these two elements of the mandatory training are overdue and are currently resourcing local trainers to undertake the training with the staff team. All residents have been risk assessed to determine their vulnerability and measures have been put in place to provide protection where necessary. The water temperatures are now controlled at source by the regulatory valves fitted. The Registered providers maintain a record of all accidents and incidents and report any relevant incidents to the relevant statutory departments. Regulation 37 reports are appropriately submitted to the Commission. NMS 36 was not formally assessed although discussions with the Registered providers revealed that formal staff supervision is not yet in place. DS0000026880.V291418.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 DS0000026880.V291418.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15(2) Requirement The Registered Providers must evidence that the Care Plans are formally reviewed regularly and updated to reflect changing needs. Please note care plans are informally reviewed and adjustments noted in the daily records Timescale for action 31/08/06 2. OP26 16(2)(k) All areas of the home must be 31/08/06 odour free. Please note this applies to one bedroom identified during the inspection and the odour did not permeate to other areas of the home. Risk assessments must be completed in respect of all windows above ground floor. Please note the Environmental health office West Dorset District Council is advising on this matter. It is recommended the registered providers seek written confirmation from EHO with regard to this matter. 31/08/06 3. OP38 13(4) DS0000026880.V291418.R01.S.doc Version 5.1 Page 24 4 OP38 13(5) The Registered Providers must ensure all mandatory training is up to date. e.g. Manual handling and infection control. 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations It is recommended that the results of the quality assurance survey/questionnaires are made available to residents, relatives. Care staff should receive formal supervision six times a year, this standard was not formally assessed however, the issue was discussed with the Registered providers. 2 OP36 DS0000026880.V291418.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000026880.V291418.R01.S.doc Version 5.1 Page 26 - 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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