Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 06/09/05 for Thistley Lodge

Also see our care home review for Thistley Lodge for more information

This inspection was carried out on 6th September 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff demonstrated a sound knowledge of their roles and responsibilities within the home. The residents are supported sensitively. The residents confirmed that the staff are supportive and approachable. They stated that they are happy with the service provided in the home. The residents are provided with detailed plans of care which identify their long term goals, the action to be taken to meet these goals and the progress made. These are devised and reviewed in consultation with the residents. The residents also have monthly meeting with their key worker to discuss their care plans and other relevant issues. The home is actively supporting one resident to gain skills to enable her to move into a more independent living environment. This resident has the opportunity to prepare her meals each day and has begun a learning programme which will enable her to take responsibility for her own medication.

What has improved since the last inspection?

Two requirements were made at the last inspection. One of these has been met in full. This was with regard to the provision of residents care plans on admission to the home and provision of additional detail to assist in the monitoring of symptoms of physical ill health.

What the care home could do better:

The requirement, made at previous inspections, to provide sufficient staffing ratios in the home in order to meet residents rehabilitation needs, social and leisure needs remains outstanding. The staffing ratios in the home reduce the residents opportunities to participate in independence promoting activities and pursue leisure activities. Some of the practices in the home reduce the residents opportunities to gain and maintain independent living skills. Some of the kitchen cupboards are locked as is the fridge, restricting access to drinks, snacks and fruit. This action has been taken in response to a risk assessment that details that some residents are at risk of eating too much, drinking too much caffeine and having poor food hygiene practices. The practice of restricting access to food and drinks increases dependency on the staff for all residents. The home must explore alternative management strategies to address the risks identified. The door to the ground floor bathroom was locked, the manager could not provide a reason for this. The residents are to be able to have unrestricted access to the bathrooms, reasons for any restrictions imposed should be clearly documented. The standard of the environment is poor, the residents are not provided with a comfortable, clean and homely place to live. An issue of serious concern was identified during the inspection. This is detailed in the body of the report. The home has not taken sufficient action to promote the health and safety of the residents and staff. Thirteen requirements relating to this have been made. The manager advised that there is a plan in place to redecorate the home and to provide fixtures and fittings that will give the house a more homely feel. At the time of the inspection, dates for the completion of this work had not been finalised. Some of the residents smoke in their bedrooms and in the bathrooms, although there is a designated smoking lounge. The manager must ensure that a risk assessments are completed and risk management strategies devised to maintain the safety of all residents and staff. Other risk assessments relating to safe working practices also require review and update. Visits to the home under Regulation 26 of the Care Homes Regulations 2001 take place each month, copies of the reports made following these visits are to be forwarded to the Commission for Social Care Inspection. Mr Doyle is to complete an application to become the Registered Manager for the home.

CARE HOME ADULTS 18-65 Thistley Lodge 40 Warwick New Road Leamington Spa Warwickshire CV32 6AA Lead Inspector Catherine Mundy Unannounced 6 September 2005 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Thistley Lodge Address 40 Warwick New Road Leamington Spa Warwickshire CV32 6AA 01926 435045 01926 435045 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Rethink Care home with nursing 8 Category(ies) of Mental Disorder (8) registration, with number of places Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17 January 2005 Brief Description of the Service: Thistley Lodge is a large, detached, three-storey house situated in a residential area of Leamington Spa. It is close to local shops and within walking distance of the town centre and local parks. The home provides services for eight people with enduring mental health problems and there are eight single bedrooms in the property. Although there is no lift in the property, there are two bedrooms and an assisted bathroom on the ground floor suitable for people with physical disabilities. There is a large garden to the rear of the property. A minibus is provided at Thistley Lodge. Thistley Lodge is staffed 24 hours a day and there is always a registered nurse on duty. The aim of the service is to provide a warm, homely environment, where staff work with service users in a supportive manner in order for the service users to achieve their maximum potential and independence. Thistley Lodge provides a permanent home for service users, although those who want to move on to more independent living are supported to do so. Thistley Lodge is part of the organisation “Rethink” (formerly the National Schizophrenia Society). Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 6th September 2005 between the hours of 11.40 am and 4.30 pm. During this time the inspector had the opportunity to meet with the residents, tour the premises, examine care plans and other documentation relevant to the management of the home and observe the interactions between the residents, the staff and their environment. Three staff members were involved in the inspection process. The homes manager was also present. In addition to this inspection a monitoring visit took place on 9th September 2005. This visit focused upon the action taken to address the issues of serious concern that are detailed in this report. It is pleasing to note that the home has made progress towards addressing these issues. Since the time of the last inspection the management arrangement of the home have changed. Mr Sean Doyle has been appointed as manager. An application to register Mr Doyle as the Registered Manager for the home has not yet been received by the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? Two requirements were made at the last inspection. One of these has been met in full. This was with regard to the provision of residents care plans on admission to the home and provision of additional detail to assist in the monitoring of symptoms of physical ill health. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: The standards within this section were not inspected on this occasion, other than to note that the Manager is in the process of updating the homes Statement of Purpose, in consultation with the residents and staff. A copy of the new Statement of Purpose is to be forwarded to the Commission for Social Care Inspection on its completion. There have been no new residents admitted into the home since the last inspection. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 The care planning system in place provides the staff with detailed information to enable them to support the residents to achieve their goals and meet the residents identified needs. EVIDENCE: A sample of two residents files were examined. The care plans examined confirmed that the residents have a comprehensive plan of care, which meets their identified needs. The residents long term goals are recorded with details of the plan in place to achieve these. The care plans have been signed by the staff team, there is also evidence that the care plans have been agreed and reviewed with the residents. Daily recording is completed detailing the progress made towards achieving each of the residents identified goals. Risk assessments have been completed relating to the residents mental health and any behavioural traits exhibited by the residents. Risk management strategies have been devised to address the risks concerned. These are subject to regular review and update. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 16 and 17 Current practices within the home promote dependency upon the staff to meet basic needs and restricts the residents opportunities to develop and maintain independent living skills. Opportunities to participate in rehabilitation and pursue leisure opportunities are limited owing to the staffing ratios within the home. EVIDENCE: The residents participate in a range of activities, these include accessing the local community, and activities within the home. Community based activities include shopping and visiting the local park. The home has recently arranged day trips, it is confirmed that the residents were able to choose the venue for these trips during residents meetings held in the home. The residents are also able go to a local nightclub. One resident attends college twice a week and another attends a structured day placement twice weekly. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 11 Activities available in the home include completing household chores, cooking and gardening. Board games are also available. The residents are able to pursue their hobbies and some of the residents have their own televisions. The length of time that the residents are engaged in a structured activity, and the frequency of these activities is dependant upon staffing ratios within the home. It has been noted at previous inspections that the staffing rota is planned to allow additional staffing in the afternoons between 1pm and 4pm, with little flexibility to support activities at other times of the day. This situation remains. The homes menus are planned in advance. A five-week rota is provided. This is changed seasonally. The manager advised that the residents are consulted in planning these menus. The residents stated that they enjoy the meals that are provided. The residents assist in the preparation of meals on a rotational basis. Each resident had the opportunity to cook once each week. One resident, in line with her care plan, prepares her own meal on a more regular basis. A risk assessment has been completed to address risks, which some of the residents present, such as poor hygiene in the kitchen, excessive caffeine intake and excessive eating. The risk management strategy in place is to restrict access to the kitchen for all residents. A number of cupboard doors are locked, as is the fridge. This restricts the access to snacks, fruit and hot drinks for all of the residents. Residents are required to ask a staff member if they want a drink or snack. Alternative risk management strategies were discussed during this inspection. One of the bathrooms on the ground floor is kept locked. The residents are dependant upon the staff to access this bathroom. The manager was unable to provide a rationale for this. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 The residents continue to be supported to access relevant healthcare professionals, in addition the system in place for the management of the residents medications is good, this enables the staff to effectively support the residents to meet their healthcare and medical needs. EVIDENCE: The residents care plans examined confirmed that the residents health needs continue to be met appropriately by the home, this is with the support of the relevant health care professional. The home also supports routine health screening, at appropriate intervals. Records are retained of all contacts with a health care professional and of the outcome for the resident. The responsibility for the management of the residents medication is retained by the home. Medication is stored securely within the home, and administered by the nursing staff. Records examined and discussions with the staff confirmed that the home continues to adopt acceptable practices. One of the residents is in the process of completing a training plan that will enable her to take responsibility for her own medication. This is clearly documented in the residents care plan. The resident has made good progress towards achieving her goal. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 13 Arrangements for the disposal of medication have recently changed for care homes, which provide nursing. Community pharmacists are no longer able to dispose of medications on behalf of these homes. The manager advised that there is a plan in place to make appropriate arrangements for the disposal of medications. The home has a very small clinical room. Space is limited and the work surfaces is cluttered. This room was also used for the storage of the residents cigarettes, residents monies, empty medication bottles, staff post and a spare toilet seat. This detracts from the purpose of the room and may hinder the nurses ability to respond to the residents nursing and medical needs effectively. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 There is no evidence of any complaints, or of any procedure to make or accept them. Practices within the home such as restricting access to food, drink and bathroom facilities, and an unclean environment and statements made by the residents that they are happy with the service provided within the home, indicates that the residents expectations are low. EVIDENCE: The homes complaints procedure is usually displayed in the entrance to the home. This was not available at the time of the inspection. The manager advised that to his knowledge no complaints, regarding the service provided had been made since the last inspection. This could not be verified as the complaints log was not available. The residents confirmed that they were confident that the staff would deal appropriately with any concerns that they raise. The residents stated that they had not had cause to make a complaint and are happy with the service that is provided by the home. The home holds regular residents meetings and operates a key worker system, where the residents have structured 1:1 meetings with a nominated staff member. This provides the residents with opportunity to raise concerns or make suggestions. The staff demonstrated through discussions that in the event of a complaint being made appropriate action would be taken. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 The standard of the environment is poor. The residents are not provided with a safe, clean, comfortable and homely place to live. Residents choice is exercised at the expense of the homes duty of care. EVIDENCE: A tour of the home highlighted areas of serious concern. This is with specific regard to the bedrooms of two of the residents. One of the bedrooms was excessively hot. This room has a large window which gets full sun throughout the day. The windows are ‘box sash’. The resident was unable to open these windows without using a book to prevent the window from closing. A fan has been provided, this did little to reduce the temperature of the room. The resident had also been provided with a jug of squash. The manager expressed his commitment to ensuring that this residents room would be maintained at a comfortable temperature. The manager advised that this would be addressed within three days of the inspection. This room also had a strong odour. The monitoring visit, on 9th September, confirmed that this resident has been provided with an air cooler, the home has taken some action to address the other issues identified. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 16 Another bedroom required thorough cleaning. It was evident that this room had not been cleaned for a significant period of time. The residents possessions were coated in thick dust, including his toiletries and face cloth. Used mugs and plates were left around the room. The resident had collected a large amount of newspapers and empty cigarette packets. There is evidence that the resident smokes in his bedroom. The staff stated that they have experienced difficulty in motivating this resident to clean his room or to allow staff to support him with this. Whilst it is acknowledged that the residents choice has been respected, the cleanliness of the room and the evident risk of fire compromises the health and safety of all of the residents and staff. The manager stated that this will be addressed within three days of the inspection. The residents care plan, inspection of the residents bedroom and discussions with the resident on 9th September, provided evidence that the home has taken appropriate action towards addressing this issue. The bedroom belonging to another resident had a curtain missing, and another residents room required deep cleaning. There is also evidence that this resident smokes in his bedroom. Areas of the home require redecoration. Walls to the lounge, above radiators are discoloured. The manager advised that there is a plan in place to redecorate the interior of the property including the residents bedrooms and communal areas. The residents confirmed that they had been consulted regarding the planned changes to the décor. The sofas in the smaller lounge requires repair or replacement. The communal areas are sparsely decorated with pictures and ornaments. During the monitoring visit to the home, on 9th September, it was noted that the home has taken some action towards improving the standard of the environment, Ornaments and flowers had been provided in the main lounge and an attempt had been made to clean the walls above the radiators. Some of the window frames are rotten and in need of repair or replacement. Flooring in the kitchen is torn and in need of replacement, kitchen cupboards are chipped and require replacement. The work surface surrounding the sink has been damaged by water. There is a bathroom and toilet on the ground floor of the home. The residents did not have free access to the bathroom during the inspection as the door was locked. The manager could not provide a rationale for this. This door was also fitted with a bolt lock on the interior. This must be changed to enable the staff to access the bathroom in the event of an emergency. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Despite the ability of the staff to perform their roles within the home the current staffing ratios restrict their ability to effectively support the residents. EVIDENCE: Three staff members participated in the inspection. Each demonstrated a sound knowledge of their roles and responsibilities within the home. The interactions between the staff and residents confirmed that the residents are supported sensitively, it is apparent that positive relationships between the staff and residents have been formed. The residents confirmed that they found the staff to be approachable and supportive. The staffing rotas examined confirmed that the home continues to provide rotational cover over a 24 hour period. Two staff members are rostered to work on each shift, one of these being a qualified nurse. The rotas provide a staffing overlap in the afternoon. Observations during the inspection, discussions with the staff and manager confirmed that the current staffing ratios are not sufficient to support the residents with rehabilitation, occupation and to develop independence. The requirement made at the previous two inspections to provide sufficient staffing to support these activities remains outstanding. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 18 The manager advised that there are currently staffing vacancies. One nurse and three care staff are required to make up the full staff compliment. The manager confirmed that the organisations recruitment procedure has been implemented. It expected that the vacant posts will be advertised in the week following the inspection. In addition the homes administrator has also resigned her post and is currently working her notice. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 and 43 The home does not take sufficient action to promote and maintain the health and safety of the residents and staff. EVIDENCE: Records examined confirmed that the home completes appropriate monitoring of fire equipment, food storage temperatures and water temperatures. A certificate was available to demonstrate that the electrical wiring is safe. Portable electrical appliance tests (PAT tests) and a gas safety certificates were not available during the inspection. Risk assessments have been completed with regard to safe working practices. These were due for review in April 2005. There is no evidence that this review has taken place. The organisation has completed a Health and Safety audit of the property. This took place on 16th June 2005. The manager advises that he is to complete and implement an action plan to address the issues raised. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 20 The home has a designated smoking lounge, there is also evidence that residents smoke in their bedrooms. Staff stated that the residents also smoke in the toilets and bathrooms. This is to be addressed to ensure the health and safety of all of the residents and staff. The fire door separating the laundry and the lounge was propped open with a spoon. This compromises the safety of the residents and staff in the event of a fire. One of the residents stated that she had wedged this door open to enable her to access the lounge more easily. Please also refer to the ‘environment’ section of this report. Visits to the home under Regulation 26 of the Care Homes Regulations 2005 have taken place periodically. The manager was able to demonstrate that, since the last inspection, these visits had taken place on 24th May 2005, 29th July 2005 and 30th August 2005. Reports made following these visits are to be provided to the Commission for Social Care Inspection. These have not been received for the two most recent visits. Since the time of the last inspection the management arrangements within the home have changed. The homes current manager took up his post within the home in May 2005. An application to register the manager with the Commission for Social Care Inspection had not been received. The manager advised that his application had gone missing, within his employers finance department. A replacement form has been sent to the manager. The inspector arranged for this, during the inspection. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x 1 Standard No 11 12 13 14 15 16 17 2 2 3 x x 2 3 Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thistley Lodge Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 1 x x x x 1 2 E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 22 yes Are there any outstanding requirements from the last inspection? 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 11, 12, 16 Regulation 12(1)(b) 18(1)(a ) Requirement Sufficient staffing is to be provided to enable the residents to have an increasesd opportunity to participate in indepenance promoting activities and to access leisure opportunities. (This requirement has been made at previous inspections.) Risk management strategies relating to accessing the kitchen are to be reviewed so as not to restrict the residents from having and preparing drinks and snacks. Bathroom doors must not be kept locked, unless there is a clear rationale for this. Any restrictions are to be recorded in the residents care plans. The complaints procedure is to be made available to the residents and their visitors. A complaints log is to be retained in the home. All areas of the home are to be maintained at a comfortable temperature. The service must ensure that the Timescale for action 30/11/05 2. 16, 17 16(2)(i) 12 (1)(b) 30/9/05 3. 16, 24 23(2)(j) 9/9/05 4. 5. 22 22 22 22(8) 17(2) Schedule 4.11 23(2)(p) 23(2)(b) 30/9/05 30/9/05 6. 7. 24 24 9/9/05 15/10/05 Page 23 Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 8. 9. 10. 24, 30 24 24, 42 16(2)(k) 23 (2)(c ) 23(4)(a ) 11. 24 23(2)(b) (c )(d) 12. 13. 14. 24 24 24 23(2)(c ) 23(2)(b) 23(2)(b) 15. 24 13(40 16. 17. 42 42 13(4) 13(4) windows are maintained to enable them to remain open if required. The service must ensure all areas of the home are clean and free from odour. The service must provide curtains where these are missing. The manager must complete risk assessments and devise risk management strategies with regard to the residents smoking in their bedrooms and in the bathroom. The service must continue with the plan to redecorate the home and provide fixtures and fittings to give the home a more comfortable and homely feel. Timescales for the expected completion of this work are to be provided as part of the action plan to this report. The service must repair or replace the sofas in the small lounge. The service must repair or replace rotten window frames. The service must continue with the plan in place to refurbish the kitchen. Timescales for the expected completion of this work are to be provided as part of the action plan to this report. The ground floor bathroom is to be fitted with a lock which can be overridden in the event of an emergency. Risk assessments relating to safe working practices are to be reviewed and updated. Confirm as part of the action plan to this report that PAT tests and gas safety checks have been completed. Documentary evidence is required. 30/9/05 30/9/05 30/9/05 15/10/05 30/11/05 30/11/05 15/10/05 30/9/05 31/10/05 15/10/05 Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 24 18. 42 23(4)(a) (c ) 26 19. 43 20. 21. 37 - 9 - The service must provide an automatic door closing device to the door between the kitchen and small lounge. Visits to the home under this regualtion are to take place on a monthly basis. Copies of the reports made following these visits are to be provided to the Commission. An application to register the manager with the Commission is to be made. - 30/9/05 31/10/05 31/10/05 - 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 6 20 20 Good Practice Recommendations It is recommended that the care plan evaluations and daily recording sheets identify the care plan to which they refer. The clinical room should not be used for storage of other items. The manager should continue to make suitable arrangements for the disposal of medicines. Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thistley Lodge E53 S4412 Thistley Lodge V248355 060905 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!