CARE HOMES FOR OLDER PEOPLE
Thistleton Lodge Care Home Fleetwood Road Thistleton Nr Kirkham Lancashire PR4 3YA Lead Inspector
Mrs Felicity Lacey Unannounced Inspection 19th April 2007 10:00 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 Thistleton Lodge Care Home DS0000006089.V330981.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. Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Thistleton Lodge Care Home Address Fleetwood Road Thistleton Nr Kirkham Lancashire PR4 3YA 01995 671088 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) Thistleton Lodge Limited Sally Clarke Care Home 57 Category(ies) of Dementia (19), Old age, not falling within any registration, with number other category (38) of places Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The home should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home may accommodate 38 service users in the category of old age (OP) and 19 service users in the dementia (DE) category. The maximum number of service users who can be accommodated at any one time must not exceed 57. 1st March 2007 Date of last inspection Brief Description of the Service: Thistleton Lodge Care Home is a very large detached property in its own grounds situated on the main Fleetwood road near to Kirkham. It is easily accessible and there is ample car parking space for visitors. The home provides care for up to 58 service users incorporating residential, respite and dementia care on the ground and first floors. Accommodation is in single and double rooms; each bedroom complies with minimum space requirements. There are four lounge areas and a conservatory. The lounge areas incorporate dining space and there is a separate dining room on the ground floor. There is a passenger lift and access for wheelchairs throughout. Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included a visit to Thistleton Lodge by two inspectors. This visit took place unannounced. Residents, relatives, staff members and the manager were spoken with during the visit. The premises were toured. The manager provided additional information in a Pre Inspection Questionnaire. 26 comment cards were received from residents, the majority of which had been completed with assistance, a relative completed one comment card and one comment card was completed by a health professional. During the visit the care plan and case notes of seven residents were looked at and six staff files were examined. Other records kept at the home were also looked at, such as the record of accidents at the home. What the service does well:
The residents who completed comment cards were pleased with the care they received at Thistleton Lodge and felt that staff listened and acted on what they said. Their comments include: ‘ (I) couldn’t be better looked after in (my) own home’ ‘I want to go home, but I am happy here they have helped me.’ ‘ I am quite happy, there is enough going on for me.’ ‘I enjoy whatever is going on. Can’t grumble at all.’ ‘Couldn’t be better if they tried.’ Relatives spoken with and who completed questionnaires felt that the staff of the home were welcoming and provided a good standard of care. A relative who completed a comment card indicated that they were very happy with the care and service provided. They commented: ‘They are always there to listen and help with any problems we have.’ Residents spoken with during the inspection thought that the care they received was of a good standard. They felt that the staff were helpful and kind. A regular programme of activities and outings is on offer. At the time of the visit a group of residents, on the unit for people with Dementia, where involved in discussion using photos of life in the 1930’s and 40’s and were thoroughly enjoying reminiscing about home life and their experiences. Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 6 Residents were confident that the staff were understanding of health needs and that medical advice would be sought when necessary. A comment card received from a health professional indicated that the staff of the home always sought advice and acted upon this to manage and improve the health of individual residents, and that privacy was usually respected. The staff spoken with felt that they were supported in their work by the manager. The manager was regarded as approachable and committed to providing a good quality service. What has improved since the last inspection?
Following the last key inspection the manager provided an Improvement plan to address the areas of concern identified. At this inspection the improvement plan was considered and progress towards improving the services offered at Thistleton Lodge was identified. There has been improvement to the decoration and furnishings of the unit that provides care for people with Dementia. There is an ongoing plan of refurbishment for the home. The standard of cleanliness has improved and the home now employs a contract cleaning company to ensure that the standard of cleanliness is maintained. Infection control measures have been put in place and this protects the health of the residents. The information gathered at the time a person comes to live at Thistleton Lodge is now transferred to the plan of care. The care plan is regularly reviewed and those looked at during the visit to the home contained relevant and helpful information. Information relating to the social history of residents, and their interests and hobbies is being gathered, this helps staff to provide relevant activities and reminds staff of the previous life experience of residents at the home. More staff have been employed at the home. The residents spoken with now felt that staff were able to respond promptly to their needs. There has been more opportunity for activities. Staff spoken with felt that they were able to provide assistance to residents and were able to spend time with residents. The newly recruited staff have received training and were confident in the support they received from other staff and the manager of the home. Training has been provided for staff and senior staff who support people with Dementia at the home. This provided information about different types of Dementia and the effects of Dementia on the person, and gave staff an opportunity to consider helpful ways of communicating with people with dementia, and positive ways of supporting people with dementia. The manager has also organised a distance learning course, which requires staff to complete a workbook. The importance of person centred care has been discussed in staff
Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 7 meetings and with staff on an individual basis. Experienced members of staff are being used to provide advice and mentor new staff to ensure that the health and welfare of residents who have dementia are promoted. The manager has implemented a regular handover meeting and recording sheet, to ensure that important information is passed on and to make sure that any health concern is acted upon. The manager has introduced a new system to ensure that accidents at the home are monitored. Mobility assessments have been reviewed, the number of falls at the home is being monitored and appropriate advice sought when individuals at high risk of falling have been identified. Medication procedures have been changed to ensure that all medication given is recorded. The owner of the home has provided monthly reports, this shows that whilst he is not managing the home, he is aware of events at the home. These visits include discussion with residents and staff members. The home must ensure that improvements made are sustained and lead to the continual improvement of the service offered. What they could do better:
The review of care plans should include the involvement of the resident and periodically where appropriate family members. This system would ensure that there was a clear shared understanding of the support needs of individual residents. Where specific instruction are made, for example if weekly weigh monitoring is recommended, this must be communicated clearly to all staff and the manager must ensure that she has a way of checking that such recommendations are being followed. It is important that relevant risk assessments are completed and are reviewed in response to changes in a persons needs. For example if a resident has a fall it is important any equipment that is used by a resident should be reviewed. A copy of all risk assessments relating to each resident should be placed on the care plan to ensure that they are easily available for all staff to read. The manager should seek Occupational Therapy advice when needed. The medication held at the home was not always recorded accurately. The number of tablets received into the home was not consistently recorded and two examples were found where it was not possible to account accurately for the number of tablets administered. The home is presently serviced by one health centre. This system does not promote residents choice. If a resident wishes to retain the services of their own GP, this should be promoted. Whilst it is understood that not all GP
Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 8 practices would agree to continue to provide services, the options available should be explored rather than choice be limited to one practice. The recruitment checks carried out by the home were not consistently followed. It is important that the welfare of residents is safeguarded by ensuring that the required references and checks have been completed for all newly appointed staff. 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. Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 9 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 Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 10 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): 3,4 Quality in this outcome area is adequate. The pre admission assessment has been improved which means that a persons needs are understood at the time of admission. The staff have undertaken training to improve their understanding of dementia care, this learning must now be consistently put into practice to ensure that the health and welfare of people on the dementia unit is promoted. Risk assessment must be up to date and accurate to safeguard the welfare of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans seen were reflective of the information gathered at the time of admission, and of subsequent changes to health and welfare. A new assessment has been introduced and an example of this being put into use was seen.
Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 11 Following the last key inspection, an experienced manager returned to the dementia unit and she has had a significant impact on the way in which the residents are now being supported. The specialist knowledge of the staff of the home is being developed. All staff who work with residents who have dementia have attended a training course, and are to complete a distance learning programme. It is important that the knowledge gained is put into practice. At the time of this visit the atmosphere and interactions observed in the dementia unit were positive and respectful. The home has made a good progress and this must be continued to demonstrate that standards can be maintained over time. Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 12 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. In the main the care plans reflected the needs of the residents and this means that health and welfare is promoted. The medication procedures of the home were not consistently followed and this may affect the well being of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All care plans have been reviewed. The review is carried out on a monthly basis by the manager and senior staff. It was not always evident if the resident had been involved. It is also recommended that periodically the care plan be reviewed with relatives, as appropriate, to ensure that a common and shared understanding of a residents support needs is reflected in the care plan. There were some examples of particular instructions not being followed, for example on two care plans specific instructions had been made to increase the frequency with which a resident was weighed. These instructions were not
Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 13 dated and had not been followed. It is important that the manager ensures the actioning of particular instructions and monitors that they are being complied with. During this visit there were examples, which showed that appropriate action had been taken in response to changes in care needs, for example analysis of the number of falls in some cases had prompted the involvement of the GP and had resulted in changes to the care plan. Risk assessments have been reviewed in some cases, however it was concerning that this had not happened in all cases, for example a recent case where a fall had occurred when a resident had tried to climb over cot-sites. The resident sustained a fracture and before returning to the home, following a period in hospital, an assessment had been completed, however the risk assessment had not been reviewed. Any equipment that is used by a resident should be kept under reviewed. A copy of all current risk assessments should be kept on the residents file to ensure that these are easily accessible for all staff. The manager should seek Occupational Therapy advice when needed. It is essential that key health and safety considerations are consistently recognised and acted upon by the manager and senior staff. The manager has implemented a regular handover meeting and recording sheet, to ensure that important information is passed on and to make sure that any health concern is acted upon. It is equally important that any changes to health are then monitored and recorded, for example a medical record entry noted bruising to a resident however this was not noted or mentioned in the daily record, it is important that significant information is consistently recorded and available to staff to enable appropriate care to be provided. There have been improved staffing levels at Thistleton Lodge and this has enabled an increase in opportunities for people to go out and about. The staff recognise the importance of physical activity for all residents and have encouraged residents to take part in gentle exercise. The records kept at the home showed that there was regular contact with health professionals, for example the community psychiatric nursing team have been involved with residents when needed. The home has a regular visit from the local GP service. The home is presently serviced by one health centre. This system does not promote residents choice. If a resident wishes to retain the services of their own GP, this should be promoted. Whilst it is understood that not all GP practices would agree to continue to provide services, the options available should be explored rather than choice be limited to one practice. Medication procedures have been changed to ensure that all medication given is recorded, this now includes supplementary drinks and creams. The medication at the home was stored securely. The medication held at the home was not always recorded accurately. The number of tablets received into the
Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 14 home was not consistently recorded and two examples were found where it was not possible to account accurately for the number of tablets administered. It is important to establish an audit trail for medication to allow all medicines received into the home and dispensed to be accounted for. Residents considered their privacy and dignity to be respected by the staff of the home. Relatives spoken said that they were able to see their relative in private. Residents are called by their preferred form of address. The need to actively promote the dignity of some residents is understood by staff and the recent training relating to caring for people with dementia, promoted person centred ways of working, this encourages staff to see each resident as an individual, and to work in ways which enable people to retain their dignity whilst offering appropriate support. Staff spoken with confirmed their commitment to providing good care which was based on understanding each residents particular needs. Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 15 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. The social and recreational needs of residents are understood and this ensures that meaningful activities are on offer. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with felt that there were a range of activities on offer if they wished to take part. The home employs a diversional therapist who provides a programme of social and recreational activities. The recent increase in staffing levels has allowed staff to spend time with residents. The staff have tried to collect information relating to the social history of residents, and their interests and hobbies, this helps staff to provide relevant activities and reminds staff of the previous life experience of residents at the home. There is now a planned programme of activities throughout the home. At the time of the visit residents told the inspectors about a recent trip out to the Bond Hotel in Blackpool, here they had enjoyed a themed afternoon, which was remembering life during wartime, this included songs from the time and food that was available during the war. The return of an experienced manager
Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 16 to the dementia unit has led to a noticeable increase in activities and outings. One lady has recently celebrated her 100th birthday and many residents were involved in preparing for the celebrations, making cards and decorations. Religious and cultural needs of residents are respected. Where possible residents are able to maintain links with their local community. The home has visits from local clergy. The mobile library visits the home. Residents felt that their personal choices where respected. The staff of the dementia unit have benefited from training in how to communicate with people with dementia, and are trying to apply their increased understanding. This will provide a setting which will enable greater choice and will help staff communicate with residents in ways which will encourage self expression and reduce frustration. One way in which this has changed the way in which the dementia unit is organised is at mealtimes; increased awareness of non verbal ways of communicating, alerted the staff to a small number of people who found the hustle and bustle of meal times difficult to cope with. This has led to a change, there are now two smaller sittings at the main meal times which had proved to be less stressful for the residents concerned. The dining area of the dementia unit has benefited from new furniture. This has been rearranged to provide a more pleasant setting. The staff showed a responsiveness to residents needs, for example they had noted that one person was particularly bothered by the sunlight during meal times, they have responded to this by ensuring that the resident sits in a chair which is not effected by this, subsequently the resident has been more settled when having a meal. The meals are considered to be nutritious and well presented. The recent quality assurance questionnaire filled in by residents showed that meals were considered to be satisfactory. There is a choice menu for all meal times, and resident’s suggestions are encouraged. The manager has recently met with the GP surgery and reviewed the number of people on dietary supplements. The manager has been advised that there is a waiting list for referrals to the dietician, however it is important that these referrals are made when needed. Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 17 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. Residents were confident that they were able to raise concerns and that these will be dealt with. The record of complaints was available at the home and this showed that complaints were responded to in line with the homes policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been two complaints at the home since the last inspection. These have been dealt with and in some cases have led to improvements in the service offered. The manager has responded promptly to concerns raised. Residents identified the manager and the dementia unit senior, as the people who would sort out any problems. The staff spoken with also felt that the manager was keen to resolve any complaints. Staff members were aware of adult protection procedures. The home has a whistle blowing policy and staff member are required to sign to say they have read and understood this. Thistleton Lodge Care Home DS0000006089.V330981.R01.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 adequate. There have been improvements in the décor and cleanliness of the dementia unit, and this has ensured that all parts of the home provide a pleasant place for residents to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the last key inspection there has been refurbishment and redecoration of some parts of the home. The employment of a contract cleaning firm has made a significant difference, and at the time of this inspection all parts of the home were found to be clean. The difference between standards in the dementia unit and that for older people has become less marked. There are plans for continued improvement in the dementia unit, with the addition of a sensory room. The manager has submitted a budget for
Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 19 the refurbishment of the bathrooms on the Dementia Unit; these are necessary improvements, which were identified at the last random inspection. The furniture in the dining room of the dementia unit has been replaced. The damage to the dresser in the lounge of the dementia unit has been repaired. There have been attempts to provide a more homely atmosphere by putting up pictures and having ornaments about. The pictures have brought brightness to the corridors, however the choice of picture and the duplication of some pictures may add to the confusion experiences by some residents. It would be advisable to have only one copy of each picture, as people often use pictures as reminders to help them get around, this is especially important in a unit for people with dementia. Infection procedures were in place. Soap, alcohol wash and toilet rolls were readily available. Gloves and aprons are provided. Soiled articles are laundered in line with infection control procedures. Thistleton Lodge Care Home DS0000006089.V330981.R01.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 adequate. The increase in staffing levels has enabled the needs of the residents to be consistently met. Training has been provided to ensure that staff have the chance to improve their skills and can provide care based on an understanding of residents needs. The recruitment procedures of the home are not consistently followed and this could place residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rota and records of staffing hours show that additional staffing has been provided. Following the last key inspection additional staff were recruited. The staffing levels throughout the home have been improved, and the employment of contract cleaners has reduced the impact of domestic work on care staff. Most residents indicated that they considered that there was usually enough staff on duty. Staff spoken with felt that they had time to carry out the duties required. The increase in staff hours on the dementia unit has made a significant difference and has allowed staff to provide a better service. Safety in the home is also better provided for, as now residents are not left unsupervised for prolonged periods. Shift patterns have also been altered to allow for increased staffing during the evening. The manager has also
Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 21 introduced additional record at night time to ensure that all residents are checked on a regular basis in line with their preferences and care needs. A programme of training and a number of staff meetings have been held since the last key inspection. Training has included Dementia Care, Infection Control and First Aid. Further training is planned, and it is important that a record of training is maintained. Staff members spoken with felt that they were offered frequent training opportunities and that the training received was relevant to their job roles. The home currently has 48 of care staff who hold a National Vocational Qualification in Care at level 2 or above. The recruitment procedure of the home has not always been followed. Of the six staff employment files checked, three had no reference form the last employer, and three did not have complete employment histories. There were also issues with the Criminal Record Bureau disclosures which had not been fully dealt with. It is important that all required checks are completed prior to employment to ensure that the welfare of residents is safeguarded. New staff who have commenced employment at the home confirmed that they had worked along side experienced members of staff during the initial weeks of their employment. The manager is active in promoting training and is aware of the need to provide induction and foundation training for new staff. Thistleton Lodge Care Home DS0000006089.V330981.R01.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 good. The manager is considered to be approachable and active in ensuring that the home provides a good service. Processes to monitor care practices and the records maintained have been introduced to ensure that the health and welfare of residents are consistently promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has returned to the home following a period of maternity leave. She has been active in compiling an improvement plan to ensure that the quality of care provided at the home is of an acceptable standard. The residents, relatives and staff held the manager in high regard, and felt that she
Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 23 was approachable and committed to ensuring that the residents received a good service. The home has an Investors in People quality award. A recent survey of resident’s views regarding staffing, meals and activities has been carried out at the home. The results of the survey should be collated and should inform continuing plans to improve the service offered. Following the last key inspection the reports required by regulation 26 of the Care Homes Regulations have been submitted. This is a way in which the owner of the home can demonstrate that they are aware of standards in the home. These reports should contain the views of residents and staff. The visits required by regulation 26 can provide another way in which the quality of the service offered is monitored. The information provided in the Pre Inspection Questionnaire indicates that the required health and safety checks have been completed. The policies and procedures of the home have been reviewed. The manager does not act as an appointee for any resident. Money is not held at the home. The home has accounting and invoicing procedures. The accident records maintained at the home have been reviewed. The accident reports are now transferred to a register in alphabetical order. This system allows the manager to analyse any trends and instigate any necessary action. There was evidence of consultation with health services regarding a number of service users who had regular falls. Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X 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 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Thistleton Lodge Care Home DS0000006089.V330981.R01.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 OP7 Regulation 13(4)(c) Requirement The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and possibly eliminated The registered person must ensure that health needs are met. (Previous time scale not met 03/12/06) The registered person must make arrangements for the recording of medicines received into the care home. The registered person must ensure that premises being used as a care home is kept in a good state of repair internally. The registered person must ensure that a person is not employed to work at the care home until required checks have been completed satisfactorily. Timescale for action 20/04/07 2. OP8 12(1) 20/04/07 3. OP9 13(2) 20/04/07 4 OP19 23(2)(b) 19/07/07 5 OP29 19 20/04/07 Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP4 OP7 OP28 Good Practice Recommendations On going training should be provided for staff regarding Dementia care and should be put into practice in all aspects of the service. The care plan must be updated to reflect the changing needs of the resident and actioned. The registered provider must ensure that at least 50 of care staff are trained to NVQ2. Thistleton Lodge Care Home DS0000006089.V330981.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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
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