Inspection on 13/02/08 for Thistlegate House

This inspection was carried out on 13th February 2008.

CSCI found this care home to be providing an Adequate service.

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 20/08/07

Thistlegate House 13/02/07

Thistlegate House 01/06/06

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 Martin Bayne Unannounced Inspection 13th February 2008 9:40 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 Thistlegate House DS0000026880.V359857.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 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. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 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 thistlegatehouse@aol.com 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 Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 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. 20th August 2007 Date of last inspection Brief Description of the Service: Mr J Corney and Mrs J Webb have owned and managed Thistlegate House, a Grade II listed building since 1994. The home has an elevated south facing position with views across the countryside and Lyme Regis bay and stands in four acres of grounds, consisting of a sunken garden, landscaped garden, kitchen garden as well as an area of natural woodland. Thistlegate House is located on the outskirts of the village of Charmouth, which is approximately 2 miles from the coastal resort of Lyme Regis. The home is registered to accommodate and provide personal care for up to 18 older people. Accommodation comprises 17 bedrooms, mainly for single occupancy on both the ground and first floor. The home has a large lounge, dining room and five bathrooms with additional WCs. One single bedroom and one double bedroom have ensuite WC facilities. There is no passenger lift in the home, however residents who have difficulty with the stairs are assisted by the staff using a Stairmatic chair, (this is a portable chair that can move down stairs and can also be used to assist residents with poor mobility around the home and out into the garden). At the time of the inspection the fees for the home range from £475 to £525 per week. Current Inspection reports are available and the home has a colour brochure, Statement of Purpose and Service User Guide providing information on the services and facilities available. Thistlegate House DS0000026880.V359857.R02.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 1 star. This means the people who use this service experience adequate quality outcomes. We (the Commission), carried out an unannounced key inspection of the home between 9:40 am and 5:30pm on 13th February 2008. The purpose of the inspection was to follow up on the 15 requirements and 3 recommendations made at the last key inspection on the 20th of August 2007 and to evaluate the home against the key National Minimum Standards for older people. We were assisted by both Mr Corney and Mrs Webb throughout the day who provided us with records that the home is required under the Care Homes Regulations 2001. In the morning we spoke with over half of the residents about their experience of living at the home. We were also able to view all of the communal areas and some residents’ bedrooms. Throughout the inspection we tracked the paperwork and records relating to two residents who had been admitted to the home since the time of the last key inspection in August 2007. Comment cards were sent to the home to be forwarded to relatives and visiting health professionals. The returned comment cards were also used to form the judgements within this report. We received three comment cards from relatives and one from a visiting health professional. At the time of the inspection there were 13 residents accommodated at the home. What the service does well: Residents’ needs are assessed prior to their being offered a place at the home and they are involved as much as possible in choosing their placement. Residents’ health needs are met at the home through the care planning system. Residents are treated with dignity at the home and their right to privacy respected. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 6 In general, residents’ social and recreational needs are met at the home and visitors are made welcome. Residents informed that a good standard of food was provided at the home. The home has a well-publicised complaints procedure and residents reported that they had confidence in the providers to act on complaints. Thistlegate House is well maintained, clean and in good repair and provides a homely ambience. The home is adequately staffed and provided with training in core subjects. What has improved since the last inspection? What they could do better: Moving and handling assessments could be improved by being more detailed. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 7 Systems need to be put in place to ensure that medication administration records are completed correctly. Where hand entries are made to the medication administration records, a second member of staff should check and sign that the entry has been made correctly. Staff recruitment practices must be carried out in line with the Regulations. New staff must not start working with residents until all recruitment checks have been carried out. The staff application form should be amended to seek information in line with the Regulations. The recommendation from the last inspection remains that staff should be trained in caring for people with dementia. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 8 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 Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from their needs being assessed before being offered a place at the home. Using one form to record the process would provide better evidence of the pre-admission assessment. EVIDENCE: We spoke to Mr Corney and Mrs Web about procedures for admitting new residents to the home. We were told it is usually relatives who make the initial enquiry and they are invited to visit the home with the prospective resident. This provides an opportunity for the home to carry out a pre-admission assessment of the person’s needs and for them to make a choice as to whether Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 10 to move into the home. If the person referred is not able to make a visit, arrangements are made for Mr Corney or Mrs Webb to visit them in hospital or their own home to carry out the pre-assessment of need. Prospective residents or relatives are given copies of the home’s brochure and Service User Guide, which provides full information about the home. At the last key inspection a requirement was made that the Registered Persons must ensure that someone qualified carries out the pre-assessment of need and that records be maintained that comment on all the areas of need identified in the National Minimum Standards for older people. We saw records completed by Mrs Webb of the visits made by the two residents tracked through the inspection, which provided evidence of the pre-assessment of need having taken place and contained a range of information relating to the needs and preferences of residents, but this information did not cover all the information under the headings listed in the Standards. Mrs Webb explained to us that once a person is formally admitted to the home, the assessment process is continued with a form that has headings for all of the topics of need identified within the National Minimum Standards for older people. We recommend that this assessment form be used as the basis to record all of the pre-admission assessment of need to avoid duplication and enabling the staff to build on the information gathered at pre-admission visits. Mrs Webb informed us that there has only been one occasion when the needs of a resident newly admitted could not be met, and this was as a result of misleading information given at the time the assessment, not the home’s assessment procedures. When residents are admitted to the home, they are offered a trial period. During the inspection over half the residents were spoken with, all of whom said that their needs were met at the home. The home does not provide an intermediate care service. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Residents health needs are met through a care planning system that takes into account the wishes of the residents, but more detailed moving and handling assessments and better monitoring of medication records are recommended to ensure that there is evidence of needs being met. EVIDENCE: At the last key inspection three requirements were made concerning care planning; that care plans must be reviewed regularly, that evidence be available to show that residents were involved in developing their care plan and that current moving and handling assessments be in place for people who need help with moving or mobilising. We found at this inspection that the requirements concerning care plans had been complied with. We looked at the Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 12 care plans for the two residents we tracked through the inspection. Mrs Webb informed us that since the time of the last inspection she had re-written care plans using a new format and template. We found a photograph of the resident and a record of key information and contacts at the front of the care plan for each of the two residents. The care plans covered all the areas of need identified in the assessment together with action expected of the staff on how to assist the person concerned. The two care plans we saw had been signed; in one case by the resident and in the other by the person’s relative, thus providing evidence that the resident or relatives had been involved in developing the plans. We also saw that reviews of care plans had taken place with dates of reviews recorded. We saw in the care plans for the two residents tracked through the inspection that risk assessments had been carried out concerning the use of the bath hoist. During the inspection we also spoke together with Mrs Web to one resident who had poor mobility, where staff needed to assist the resident using a hoist. We saw that a moving and handling assessment had been carried out on behalf of this person; however we recommend that more detail be recorded about the instructions for staff on how to assist this resident and other residents with similar needs. At the last inspection a recommendation was made that more detail be provided concerning oral health, social interests and relationships, and personal safety. We saw that in the new care plan documentation there was a section for this information and in the completed care plans information under these headings had been recorded. Mrs Webb also informed us that staff had recently been on a training course concerning oral health. We saw certificates, which confirmed this. We saw the daily notes recorded by care staff for the two residents tracked through the inspection. There was evidence that staff were carrying out instructions as detailed within the care plans. There was also evidence of how health and social care needs of residents were being met. We found that each resident is registered with a GP and that visits from doctors are recorded. At the time of the inspection one person was being visited by a community nurse to attend to dressings. We also saw that a chiropodist visits the home regularly and that arrangements are made for residents to see a dentist if this is required. One resident we spoke with informed us that arrangements had been made for them to see a dentist on the day of our visit. At the last inspection the report commented upon there being no skin care risk assessments. Prior to this inspection, Mr Corney had arranged for a letter to be sent from one GP practice that said that residents’ skincare was attended to at the home and that appropriate referrals were made if problems were identified. The feedback from residents and the returned comment cards informed that residents were treated with dignity and respect. We discussed with Mrs Webb the arrangements made for administering medication in the home. We were told that currently all of the residents have Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 13 their medication administered by the staff. We were informed that only staff who had received training in safe administration of medication give out medication to residents. We were also told that where an untrained member of staff gave out medication they were always supervised by a trained member of staff. A medication training certificate was seen for the senior carer on duty on the day of the inspection. We saw the medication administration records for all of the residents. At the last inspection it was recommended that these record were audited monthly to ensure that the records are completed in full. We found that there were several gaps in the records for administering of Lactulose, (this is a laxative medication). This was discussed with Mrs Webb together with procedures that could be put in place to ensure that errors are picked up so that records are completed in full. This will be monitored at the next inspection. We recommend that where hand entries have to be made onto the medication administration records, these are signed and checked by a second member of staff to ensure that the record has been entered correctly. We found that suitable procedures were in place for the storage of medications that require refrigeration, with these being kept in a lockable container within the fridge and dates recorded for opening these medicines. The home uses a unit dosage system with medications being supplied to the home. The pharmacist visits the home to advise and report on the procedures within the home and we saw the medication reviews carried out by the pharmacist; these reported that the home had good systems for managing residents’ medication with no problems identified. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from their social, leisure and recreational needs being met and through visitors being made welcome to visit the home. The home provides a good standard of food. EVIDENCE: At the last inspection a requirement was made that after consultation with residents, the Registered Person must provide social activities to meet individual needs. In the afternoon of our inspection a person was visiting the home for a light exercise programme with residents in the lounge. We were informed that on occasion entertainers such as singers are brought into the home. We spoke with residents, some of whom said they preferred to spend time within their rooms and occupy themselves, whilst others said they chose to spend more of their time in the communal areas. One resident informed us Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 15 that they enjoyed reading and that Mr Corney had arranged for the library to visit the home. Another resident told us that they had been assisted in purchasing a radio as they enjoyed listening to the radio in their room. One resident told us that they had recently had a birthday and that this had been celebrated by the staff decorating her room and providing a birthday cake. Another resident informed us that they had a daily paper delivered to them. Two of the returned comment cards provided by relatives informed that in their view more communal activities could be organised in the home for the residents. Of the residents we spoke with, one person said they would benefit from more activities but the others said they were happy with the level provided. We recommend that wishes and views of residents regarding activities and meeting social needs be kept under review. Residents we spoke to told us that visitors were very were made very welcome at the home and at the time of inspection one resident was being visited by relatives. We spoke with these relatives who told us they had been very happy with the care provided at the home and that they had peace of mind that their relative was being well cared for. Residents told us that they were very happy with the standard of food in the home and the choices that were offered. We saw the records of food provided and this reflected that there was a varied and balanced diet being offered to residents. We saw that one resident who required a gluten-free diet had their needs catered for. Residents told us that they have their breakfast brought to them in their rooms and that the main meal of the day is served at lunchtime in the dining room. Residents who require assistance with feeding or who prefer to have the main meal within their room can request this. Mr Corney informed us that the home has a kitchen garden, which is used to supply fresh seasonal vegetables. The home also has its own spring that supplies the drinking water in the home. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well publicised complaints procedure and policies and procedures being in place for the protection of vulnerable adults. EVIDENCE: The complaints procedure for the home is detailed within the contract and also within the Service User Guide. When a new resident comes to live at the home, they or their relatives are given a copy of both these documents. It was agreed at this inspection that a copy of the Service User Guide would be made available in the home so that residents have ready access to the complaints procedure in case they did not keep the copy they received when they were admitted. The residents we spoke with said that they had no complaints and they had confidence that they could take complaints to Mr Corney or to Mrs Webb, to be dealt with appropriately. A requirement was made at the last inspection that the home’s vulnerable adult’s policy be amended, as this did not reflect the local protocols concerning ‘whistle blowing’. We saw the homes policy and discussed amendments that Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 17 were still required. Mr Corney sent a revised and amended copy of this policy after the inspection, as agreed. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a clean, ‘homely’ and well maintained environment. EVIDENCE: As part of the inspection we were shown around the home and were invited to view some residents’ bedrooms. We found the home to be clean, in good decorative order throughout and furniture and fittings in a good state of repair. It was apparent from the residents’ bedrooms we saw that residents are able to bring their own furniture and personalise their rooms. At the last inspection it was noted that one of the bathrooms were showing signs of wear and tear. We were told at this inspection that there were plans to have the bath replaced Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 19 in this bathroom within the next six months. This will be followed up the next inspection. At the last inspection it was also noted that communal toiletries and hand towels were found in bathrooms that undermined infection control policies. At this inspection we found that paper towels were available in all the bathrooms and there were no communal toiletries in bathrooms. We were told that residents could use their own soaps and toiletries but these would be returned and kept in residents’ bedrooms. At the last inspection a repeat requirement was made concerning the risk assessments for windows above the ground floor. Mr Corney told us that risk assessments of these windows had been carried out in the past and that the risks remained the same. Mr Corney said that it was not possible for residents to fall from windows above ground floor but that in some cases it was possible for a resident to climb out. In view of the listed status of the building there were difficulties in fitting window restrictors to these windows and Mr Corney said that current arrangements had been cleared with the Environmental Health Officer. It was agreed that Mr Corney would review the risk assessments and sign and date these reviews to demonstrate that the situation was being monitored. (Copies of the reviewed risk assessments were forwarded to the Commission by Mr Corney as agreed). We were told that part of the assessment process for new residents was to assess indications of depression or past suicidal behaviour and should there be cause for concern, the person would be accommodated on the ground floor. Mr Corney informed us that he had contacted Environmental Health seeking written confirmation regarding their views about the safety concerns of these windows. He informed that he had received a response but that Environmental Health had referred the matter back to the Commission. A copy of this letter was shown to us. It was noted that some radiators within the home had been covered as a result of risk assessments indicating a potential for these radiators to cause burns to residents. Mr Corney told us that there was a programme for covering all of the radiators based upon the risk assessments whilst ensuring that they were in keeping with the taste and the aesthetics of the building. Progress in achieving this will be reviewed at the next inspection. The hot water system is temperature regulated to ensure that residents are not placed at harm from scalding water. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and training meet the required standard. EVIDENCE: We were informed that there are three care staff on duty in the home from 7:30am to 6:30pm. From 6:30pm to 10pm there are two staff on duty and during the night-time period there is a one awake member of staff with sleepin staff also available on duty. We were also informed that before the beginning of each shift there is a handover period for staff to inform the next shift of any developments and concerns about residents. In addition to the care staff, Mr Corney and Mrs Webb are available in the home each day. The home does not employ domestic staff, these duties being carried out by the care staff. The home employs a person who has responsibility for ensuring general maintenance of the home and the gardens. Chefs are employed seven days a week. A duty roster was shown to us that reflected the above staffing. From discussions with residents and with Mr Corney and Mrs Webb it was felt that this level of staffing met the needs of the residents currently accommodated at Thistlegate House. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 21 At the last inspection a requirement was made concerning staff recruitment as it had been found that in one case references had not been returned, and in another case there was no evidence of returned Criminal Records Bureau check before the person had started working with residents in the home. Since the last key inspection in August 2007 we found that two new members of staff had been recruited to the staff team. We looked at their recruitment records. The home has an application form that applicants are required to complete. We recommend that wording be changed concerning references, to ensure that references are taken up from a person’s last place of work of not less than three months where they worked with children or vulnerable adults. We found that all the recruitment checks and records, such as the recent photograph, proof of identity, health declaration, the taking up of references and an application for a Criminal Record Bureau check (CRB) and check against the register of people deemed unsuitable to work with vulnerable adults (POVA) were in place. We found however that one member of staff had started to work with residents before the return of the check against the register of people deemed unsuitable to work with vulnerable adults. The need for such checks to take place before people start working with residents was discussed and a requirement was made that staff must not work with residents until the check has been returned against the POVA register. Failure to comply will result in enforcement action. The returned annual quality assurance assessment document stated that of the permanent care staff, 65 had achieved NVQ level 2 or above. Mrs Web showed us training certificates for a sample of the staff team. Since the last inspection in August 2007 nine staff have been trained in stoma care, six staff in oral health and hygiene and nine staff in use of equipment for diabetes. A course had been planned in bereavement training but this training had been postponed by the trainer. A recommendation was made at the last inspection that training be offered to the staff in caring for people with dementia. This has yet to be acted upon and the recommendation is carried forward in this report. A sample of training certificates were seen for staff concerning moving and handling. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was found to be generally well managed; however there is a need for the providers to complete the management qualifications and residents are potentially put at risk by staff beginning work at the home before they have been cleared against the register of people deemed unsuitable to work with vulnerable adults. EVIDENCE: Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 23 A repeated requirement has been made that the Registered Persons must have a qualification relevant to the management of the home. Mr Corney showed us a facsimile from a training organisation that informed that both he and Mrs Webb were enrolled on NVQ level 4 Management and the Registered Manager’s Award. The requirement will remain until such time as the qualifications have been awarded. At the last inspection it was found that the testing of the fire safety system and equipment was not taking place to the required timescale. We saw the fire log book and found tests and inspections were now taking place as required. At the time of inspection an outside person was visiting the home to carry out a fire risk assessment of the building. At the last inspection a requirement was made concerning the Control of Substances Harmful to Health (COSHH). At this inspection we found no cleaning or other harmful products in communal bathrooms or areas where residents had access. We recommend however that a register of products and safety information be collated and kept in line with COSHH guidelines. Thistlegate House DS0000026880.V359857.R02.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 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 X 3 x x 2 Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 25 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 OP29 Regulation Schedule 2 Requirement The registered person must ensure that all of the recruitment checks and stipulations of Schedule 2 are complied with concerning the recruitment of new members of staff. The registered person must have a qualification relevant to the care provided. An action plan must be submitted that sets out the deadline for the achievement of this qualification This requirement will remain in force until completion of NVQ level 4 in management and the Registered Manager’s Award. Timescale for action 07/04/08 2. OP31 9(2)(a) 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 26 No. 1. 2. 3. Refer to Standard OP3 OP7 OP9 Good Practice Recommendations It is recommended that the assessment form be used to record all of the pre-admission assessment information. It is recommended that more detail be written as to risk concerning moving and handling and how these risks are to be minimised. It is recommended that the registered manager monitor medication records to ensure that medication is being administered and recorded. Where hand entries are made to the medication administration record a second member of staff checks and signs that the entry has been made correctly. It is recommended that residents’ wishes concerning their social and leisure interests be kept under review, in order for their needs to be met. It is recommended that the staff application form be amended to seek a reference from the person’s last place of employment of not less than three months where they worked with children or vulnerable adults. It is recommended that specialist training is available to staff who care for people with specific needs i.e. dementia. It is recommended that the registered person maintain a COSHH register and ensure that all substances identified on the register are kept in line with the COSHH legislation in order to protect those who use the service. 4. 5. OP12 OP29 6. OP30 7. OP38 Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thistlegate House DS0000026880.V359857.R02.S.doc Version 5.2 Page 28 - 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. 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