Inspection on 20/08/07 for Thistlegate House

This inspection was carried out on 20th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 John Hurley Key Unannounced Inspection 10:00 20th August 2007 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.V345792.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thistlegate House DS0000026880.V345792.R01.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 F/P01297 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 Thistlegate House DS0000026880.V345792.R01.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. 13th February 2007 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 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, 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, optical and chiropody services can be arranged as required. Fees range from £475.00 to £525.00 per week. Current Inspection reports are available and the home has a colour brochure providing information on the services and facilities available. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection of Thistlegate House care home for the inspection year 2007/8. The inspection process followed the Commission for Social Care Inspection Inspecting for Better Lives methodology. The views of the people who use the service and people important to them were sought; where appropriate their comments are included in this report. Two inspectors carried out the inspection over a five-hour period. The inspectors toured the building, spoke with the manager, staff on duty and spoke privately with people who use the service on both an individual and group basis. They inspected a sample of the documentation relating to the individuals who reside at the home along with records relating to staff and other documents required by regulation. What the service does well: What has improved since the last inspection? The inspectors were unable to note any significant improvements in service delivery since the last inspection. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 6 What they could do better: The registered person and registered manager must ensure that • • • all requirements set are fully dealt with by the prescribed time scales and any recommendations given due consideration. That statutory requests for information are complied with by the prescribed time scales. all initial assessments contain the information required under standard 2 of the National Minimum Standards, contain a statement that their assessed needs can be met and also include a record of the individuals comments. all people who use the service have a detailed care plan which is reviewed on a monthly basis and agreed with the person who uses the service or people important to them so as to ensure that the care provided is based on individual and emerging needs. all manual handling assessments are reviewed and any action that is required to ensure the safety of the people who use the service and staff are recorded and acted upon. activities are provided based on individual needs and aspirations. all environmental risks are assessed and the identified action to minimize the risk is recorded and acted upon to minimize the risk of harm to people who use the service and staff. protection of vulnerable adult (POVA) policies reflect the local authorities policy. staff receive training relating to POVA. robust employment practices must be established in order to protect the people who use the service. all new staff receive a formal recorded induction in order to demonstrate that the person’s fitness to carry out the tasks they are to perform. all staff receive statutory training and regular updates in order to continue to demonstrate the person’s fitness to carry out the tasks they are to perform. the registered manager completes the NVQ in care management all staff receive regular recorded supervision. DS0000026880.V345792.R01.S.doc Version 5.2 Page 7 • • • • • • • • • • • Thistlegate House • • • the findings of the homes quality audit must be made available to those who use the service and other partner agencies. COSHH records and requirements are maintained at all times. That weekly fire alarm and equipment tests are carried out and recorded. 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.V345792.R01.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.V345792.R01.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): 2,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information provided by the home gives sufficient details about the service on offer enabling people to make an informed choice. The preadmission assessments do not identify key issues that may affect the well being of the people who use the service. EVIDENCE: The inspector viewed the statement of purpose relating to the home. This document when read in conjunction with the service user guide provides the information with which to make a judgment as to the service on offer. The Registered Manager generally ensures that arrangements are made to carry out an assessment of need, which in the main is completed prior to any prospective resident moving into the home. However, gaps in this process Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 10 were found. The inspector sampled files relating to information about individuals living at the home and their pre admission assessments. They found that the individual’s assessments generally cover the areas required. However they lacked the detail with which to make a comprehensive statement that the home could met the assessed needs. In one case the registered manager could not produce a pre admission assessment when asked. As reported at the last inspection there was no evidence of any discussions between prospective residents or people important to them and the home to make sure all the individual’s needs were recognised and included in the care plan. The home does not provide intermediate care. Thistlegate House DS0000026880.V345792.R01.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 is adequate This judgement has been made using available evidence including a visit to this service. Care records do not provide sufficient detail to ensure that the resident’s health and personal needs are being fully and safely met. The home has systems in place for managing residents’ medicines but some aspects need improving to protect residents. EVIDENCE: The inspector sampled the resident’s documentation in relation to care planning and review. Not all individuals have a care plan that fully demonstrated their needs and how these should be met. The information supplied at the initial assessment is limited so it is not possible to say if the persons care plan reflects the needs at the time of admission or thereafter. Through sampling the documentation relating to people who use the service the inspectors could find no formally recorded review of individuals needs. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 12 It would be helpful if pressure ulcer assessments were undertaken to ensure that any person who uses the service is not at risk of developing pressure ulcers due to the lack of acknowledgement of the possible risk. The recommendation to ensure that greater detail and an explanation of the care to be provided is available for staff in the care plans, especially oral health, social interests, relationships and personal safety has yet to be acted upon. At the time of the inspection no individual who uses the service was responsible for his or her own medication. The inspector sampled the medication administration records and found them to be generally kept in good order. There was however a few gaps in the recording of medication. The registered manager was unaware of this and so it would therefore be helpful if they introduced a medication quality control audit that would identify these errors. This would then give them the opportunity to ensure that action was taken to avoid this happening again thus ensuring safe medication practices for the people who use the service. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 13 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. The home would benefit from identifying people’s social care preferences to ensure that they are satisfying their social and recreational interests and needs. The flexibility of the home enables people to maintain contact with their family and friends The meals that are provided appear to meet the expectations of the people who use the service. EVIDENCE: People who use the service receive visitors whenever they wish. A record is maintained of all visitors to the home. The home encourages friends and relatives to keep in contact. Visitors spoken with confirmed that they were always made welcome by the staff. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 14 The people who use the service confirmed that they could spend their time as they want to and that they are given choices. The inspector toured the building and noted that many of the service users’ rooms were personalised with their own possessions. At the last inspection it was recommended that the wishes, expectations and preferences of residents are recorded regarding opportunities for social stimulation. The documents available did not evidence that this recommendation had been acted upon. The registered person informed the inspectors that a new member of staff was addressing this issue with the people who use the service. There are planned activities, which provide some stimulation to the resident group. Several people told the inspector that they knew what activities were taking place, some they liked others they did not. At the time of the visit there was insufficient social stimulation for those with enduring mental health issues. One individual was identified by management as being highly dependent. The inspectors did not observe any stimulation of this individual with exception of being assisted with their lunch, during the inspection. Breakfast is generally served in the individual’s own bedrooms. People who use the service reported to the inspector that they liked this. An inspector spoke with people shortly after dinner. Those who could articulate a view expressed satisfaction with the food on offer and further confirmed that they had a choice of what to eat. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 15 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 poor. This judgement has been made using available evidence including a visit to this service. At the time of writing this report an issue of concern is currently under investigation by the statutory authorities, the safety and welfare of residents and staff are being monitored in order to ensure their safety. EVIDENCE: The home has a complaints procedure, that includes details of external agencies that people who use the service and their families may contact, including the Commission for Social Care Inspection. The individuals who the inspector spoke with confirmed that they knew how to make a complaint and to whom. They informed the inspectors that they considered complaints are dealt with. The inspectors looked at the home’s vulnerable adults policy and found that it does not reflect the current local authorities protocols. The policy states that staff must report all concerns to the registered manager or registered person. The Commission for Social Care Inspection considers that this statement does not demonstrate a transparent and open approach to vulnerable adults and procedurally stops staff from “Whistle Blowing” Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 22, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Risk assessments have not been robustly completed which may put those who use the service at risk. Plans need to be made to carryout internal investment of the communal bathrooms. In general terms people who use the service have specialist equipment to meet their current needs but more suitable arrangements need to be made for this equipment to ensure that dignity is maintained. EVIDENCE: The inspectors toured the premises looking at all communal areas and residents’ bedrooms. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 17 The communal dining room and lounge are comfortably furnished to a good standard as are the hallways and corridors. There are several bathrooms available to those who use the service but in general only two are used. One of these bathrooms was showing signs of wear and tear and plans should be made to refurbish this in the near future. In all of the bathrooms the inspectors found communal toiletries and hand towels thus undermining infection control policies. The overall standard of cleanliness and hygiene in the communal areas and residents’ private rooms appeared to be generally satisfactory although two of the bedrooms had unpleasant odours. The home does not employ a cleaner or laundry person; care staff as part of the duties carry out these tasks. The registered persons said these arrangements continue to be under review but they are advertising for a domestic assistant. This was also the case at the last inspection. The home employs a person who has responsibility for ensuring general maintenance of the home and the gardens. The gardens appear well maintained and provide a safe and private space for people who use the service. In general terms the residents rooms have been personalised to reflect the individuals tastes where possible. The individuals spoken to expressed satisfaction with the rooms they have. The inspector noted hoists and lifting aids to enable the safe handling of people who use the service. The service records for these pieces of equipment were found to be in good order. It was noted that these pieces of equipment stay in the person’s room all day. The registered person agreed with this observation. It is considered that this practice undermines the dignity of the person and should only be kept in the room for the staff’s benefit. The requirement made at the last inspection to complete risk assessments in respect of all windows above ground floor has yet to be attended to. It was noted at the last inspection that the Environmental Health office, West Dorset District Council is advising on this matter but no evidence was offered during the inspection to suggest that this advice had been obtained. Similarly the risk assessments relating to the radiators were generic in nature and did not recognise the abilities of those who may be affected by any danger they may present. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The amount of staff on duty may not meet the emerging needs of the people who use the service. The recruitment and employment practices within the home do not consistently protect the residents from the risk of unsuitable staff being employed. Shortfalls in staff training mean that people who use the service cannot be assured that they are in safe hands at all times. EVIDENCE: Duty rotas are maintained. There are generally three staff on duty throughout the day along with the registered manager and registered person. There is one waking staff at night. As mentioned earlier there is no additional domestic staff. The registered manager and registered person informed the inspector that they work as members of the care team although the hours that they work and in what capacity is not identified within the rota. Through discussion with the registered manager the inspectors were informed that one of the people who use the service needs and receives high levels of input from the staff. This individual was seen in a chair in their room and the Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 19 inspectors regularly checked on the input this person received whilst they visited. Over the period of one hour in the afternoon no one came to see this individual. As this person is not the only person who is highly dependent it is hard to see how all people who use the service receive the care and attention they should given the number of staff available on any given shift. A comprehensive training matrix is not maintained. No evidence was supplied at the time of the inspection to evidence that staff do not receive regular updates in mandatory training. The inspectors were informed that newly appointed staff follow an induction programme but there was no evidence to support this. Staff do not receive regular written supervision or appraisals. At the last inspection a requirement was made to ensure that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. Recruitment records were examined for the last member of staff to have been recently employed by the home. Although references had been sent for none had been returned. The home had applied for a POVA First check and enhanced CRB disclosure for the member of staff but there was no evidence that these had been returned although the person in question had started work at the home. This person was seen to work unsupervised at the time of the inspection. There were no risk assessments associated with the person’s employment and no supervision details were available. The boundaries to which they could work within were not recorded. There was no written evidence of any formal induction. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered persons failed to respond to requests for information about the home as required by statute. The registered persons have failed to respond to the previous requirements thus putting service users at risk of harm. The practices relating to the Control of Substances Hazardous to Health do not comply with the associated regulations and therefore put people at risk. Insufficient management relating to the weekly testing of fire safety equipment may put people who use the service at risk. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 21 EVIDENCE: The proprietors had been asked to provide an Annual Quality Assessment Audit (AQAA) data set as required by statute on the 14 of June 2007, the return date was set at the 1st July. On the 8th August 2007 the inspector wrote to the proprietors requesting that they return this information by 18th August. The proprietors rang the commission and asked for more time to complete the data set. At the inspection the inspectors asked when the information would be received, it was suggested by the end of that week. At the time of writing the report this data set and assessment has yet to be received. At last year’s inspection five requirements were made for the management and registered person to attend to. Two of these requirements were to have been attended to was 30th July 2007. There was no evidence that any of these requirements had been attended to in full. The registered manager had not contacted the Commission for Social Care Inspection to indicate there was any problem in addressing these issues. Similarly little progress had been made in implementing the recommendations that were made. The registered persons, despite owning and managing Thistlegate House for many years, have yet to complete the final part of the NVQ in management. The inspectors discussed with the registered manager the requirement for the registered persons / manager to have obtained this qualification. The registered persons informed the inspectors that this issue was being addressed with the local college but no evidence was made available to support these representations. The providers informed the inspectors that they had carried out a quality assurance audit but have yet to assess the findings of this audit. No evidence was offered to the inspectors regarding this issue. It was found that not all people who use the service have a recent photograph on file, it would be helpful if they did. Photographs are also important when new staff are employed or if the home uses agency staff to assist with identification. It is also useful to include the person’s photo to aid others if a person who uses the service goes missing. Small amounts of cash are kept by the home on behalf of the people who use the service. A quick sampled audit found that the actual amount held corresponded with the amount in the safe. Records were available to demonstrate that equipment used in the home such as hoists, had been serviced. The management were asked about the weekly testing of the fire safety equipment. The inspectors were informed that this had not happened for some time and this would be a duty for the new member of staff to perform. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 22 As mentioned under the staffing section staff have yet to receive documented supervision. During the tour of the building the inspector noted that the Control of Substance Hazardous to Health regulations had been breached. This was evident in the number of substances that were in unlocked cabinets in communal bathrooms, the number of substances that had been decanted in to alternative containers (without the correct labelling needed when diluting substances) and the failure to maintain a full and comprehensive register of what substances are on the premises. Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 1 3 x 3 x x x 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 x 3 x x 1 Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 24 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. Standard 1 OP3 Regulation 14 schedule 3 (a) Requirement The registered person must ensure that someone qualified to do so makes the initial assessment of need for all prospective service users. The records made must comment are all areas identified in standard 3 of the Care home regulations , Care Standards Act 2000. The registered person must ensure that the residents care records include an action plan with sufficient detail to provide clear guidance to staff on the actions to be taken to meet all their identified needs. The resident or their representative must be consulted when preparing the care plan and sign the plan to evidence they agree with actions taken on their behalf. The registered person must ensure that all care plans are kept under review to ensure that people who use the service needs are recorded and being met. DS0000026880.V345792.R01.S.doc Timescale for action 30/09/07 2 OP7 15(1)(2) 10/10/07 3 OP7 14 (2)(a)(b) 21/09/07 Thistlegate House Version 5.2 Page 25 4 OP7 13(4)(c) The registered person must ensure that all manual handling assessments are up to date and reflect the current needs and assessments of the people who use the service. After consultation with the people who use the service the registered person must provide social activities to meet their individual needs. Previous timescale of 30/06/07 has not been met. 30/09/07 5 OP12 16(n) 10/10/07 6 OP31 Not specified The registered person must 30/09/07 ensure that all statutory requests for information are complied with in a timely fashion. This is in relation to requests to have a completed AQAA returned. The registered person must ensure that the homes policy with regards to vulnerable adult reporting reflects the local authorities policy in order to protect those who use the service The registered person must be able to evidence that all staff are trained in the Protection of Vulnerable Adults in order to protect those who use the service 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 The previous timescale to meet this requirement was the 30/06/07 this was not met. 30/09/07 7 OP18 13(6) 8 OP18 13(6) 10/11/07 9 OP31 9(2)(a) 30/09/07 Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 26 10 OP33 24(1)(a)( b)(2)(3) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, and other stakeholders must be in place to measure success in meeting the aims, objectives and the statement of purpose of the home. The previous timescale to meet this requirement was the 30/06/07 this was not met. The registered persons must ensure that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice in order to protect those who use the service. The previous timescale to met this requirement was the 30/04/07 this was not met. 30/10/07 11 OP36 18(2) 30/09/07 12 OP38 13(5) The registered persons must 30/09/07 ensure all mandatory training is up to date. e.g. Manual handling, infection control, and fire training in order to protect those who use the service. The previous timescale to met this requirement was the 30/03/07, this was not met. 13 OP38 13(4) 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. DS0000026880.V345792.R01.S.doc 30/09/07 Thistlegate House Version 5.2 Page 27 The previous timescale to met this requirement was the 30/04/07, this was not met. 14 OP38 13(4)(C) The registered person must establish and 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. The registered person must ensure that the weekly fire equipment checks are carried out and the results of these checks recorded in order to protect those who use the service or work at the premises. 10/10/07 15 OP38 23(4) 25/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered person/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is recommended that the registered manager introduce a monthly audit of the medication records to ensure that medication is being administered and recorded. It is recommended that greater details and an explanation of the care to be provided is available for staff in the care plans, especially oral health, social interests, relationships and personal safety. It is recommended that peoples weight is monitored to promote the persons health care needs. 2. OP7 3. OP8 Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 28 4. OP27 Sufficient numbers of staff must be on duty at all times to ensure the needs of residents can be met. Please note the Registered Providers are in the process of recruiting two full time staff. 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 storage of aids does not undermine the dignity of those who use the service.. It is recommended that steps are taken to ensure that there are no unpleasant odours in the service users rooms. 5. 6. 7 OP30 OP10 OP10 Thistlegate House DS0000026880.V345792.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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.V345792.R01.S.doc Version 5.2 Page 30 - 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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