Inspection on 08/02/06 for Thistley Lodge

This inspection was carried out on 8th February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thistley Lodge 30/08/07

Thistley Lodge 06/09/05

Thistley Lodge 17/01/05

Thistley Lodge 02/06/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Thistley Lodge 40 Warwick New Road Leamington Spa Warwickshire CV32 6AA Lead Inspector Catherine Mundy Unannounced Inspection 8th February 2006 10:50 Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 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 Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thistley Lodge Address 40 Warwick New Road Leamington Spa Warwickshire CV32 6AA 01926 435045 01926 435045 thistley@rethink.org 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) Rethink Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 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 DS0000004412.V282595.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection of this home in the 2005/06 inspection year. This inspection focuses upon the key standards that were not inspected at the previous inspection and on the progress made towards meeting the requirements made. For a full overview of this service this report should be read alongside the report that was made following the last inspection of the home, which took place on 6th September 2005. This inspection was unannounced and took place on 8th February 2006, between 10.50 am and 1.50 pm. The inspection included a tour of the home, discussions with residents and staff, observations of the interactions between the residents and staff and examination of documents relating to the residents and the management of the home. The homes manager was present for part of the inspection. A pre-inspection questionnaire has been completed by the manager. In addition to the inspection that took place on 6th September the home has also been visited, on several occasions, to monitor the progress made towards meeting issues of serious concern identified at the last inspection. The feedback from these visits is included in the body of this report. Since the time of the last inspection the manager has resigned his post. Currently a manager from another home within the organisation is undertaking this role until a new manager is recruited. What the service does well: What has improved since the last inspection? There is a vast improvement in the cleanliness of the home. The residents take responsibility for cleaning the communal areas and their own rooms. The level of support required is detailed in the residents care plans. These are regularly reviewed. This work must continue. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 6 Communal areas of the home have been decorated giving the home a more comfortable and homely feel. The residents confirmed that they were consulted about the new colour scheme. The home has reviewed the practices that were evident at the last inspection, which promoted a dependence upon the staff. The risk assessment relating to the residents access to the kitchen has been reviewed. Residents are now able to make drinks and snacks when the wish. The ground floor bathroom is no longer locked. What they could do better: Fourteen requirements have been made following this inspection. Seven of these are outstanding from previous inspections of the home; two of these have been met in part. Risk management strategies are to be reviewed to ensure that they are effective in addressing the risks identified in relation to the residents smoking in their bedrooms. Although the residents are clear about the restrictions imposed with regard to smoking in undesignated areas, there is evidence that some of the residents continue to smoke in their bedrooms, placing themselves and others at risk. The home has made some significant improvements to the standard of the environment. However some of the requirements that were made, in relation to the environment, at the last inspection remain outstanding. The sofa in the small lounge has not been repaired or replaced. The window in one resident’s bedroom has not been fixed, to allow it to remain open if required. The paintwork to the exterior of the property requires attention; rotten window frames have not been repaired or replaced. Curtains or blinds are to be provided in the lounge and first floor bathroom. The kitchen requires refurbishment in order to comply with Environmental Health legislation. The Environmental Health Officer intends to serve an improvement notice on the home to address this. 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 house meeting records show that since the last inspection some planned activities have been cancelled due to staffing shortages. The home has recruited new staff members to fill staffing vacancies within the home. It is of concern that on the day of the inspection two new members of staff were on duty. These staff members had commenced employment in the week before the inspection. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 7 Discussions with these staff indicated that they had not completed a thorough induction to the home. Although essential training is planned, this had not yet been delivered. The recruitment files identified that acceptable recruitment procedures had not been followed. One staff member did not have an enhanced CRB disclosure. 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 DS0000004412.V282595.R01.S.doc Version 5.1 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 9 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 the following standard(s): x EVIDENCE: The standards within this section were not assessed on this occasion. These standards have been met at previous inspections. There have been no new residents admitted to the home since that time. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 6, 7 and 9 Risk assessments and related care plans require further review and update to promote the health and safety of all who reside in the home. The residents are supported to make decisions about the issues that affect them. EVIDENCE: An issue of concern was raised at the last inspection with regard to the cleanliness of the resident’s bedrooms and smoking in bedrooms and bathrooms, this has been monitored in additional visits to the home and during this inspection. A sample of two residents care plans were examined. These included detailed risk assessments and plans of care to address the issues identified at the last inspection. These had been agreed with the residents and are regularly reviewed. The residents confirmed that they are aware of the content of these plans and of the restrictions imposed with regard to smoking. Recording of the progress made towards achieving these plans is made at appropriate intervals. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 11 These indicate that the care plans relating to hygiene are effective. The cleanliness of the bedrooms belonging to these residents has improved, this work must continue. Despite the agreements made between the residents and the home and there is evidence that the residents continue to smoke in their bedrooms. The staff stated that they had found cigarette ends in one resident’s bedroom on the morning of the inspection; this room had an odour of cigarette smoke. The guttering outside the other resident’s bedroom window was littered with cigarette ends and matches. These appeared to have been discarded recently. The manager expressed her commitment to reviewing the residents risk assessments and relevant care plans as a priority. Discussions with the residents and examination of care plans and other documents confirmed that the residents are supported to make decisions regarding their every day lives. Care plans are agreed and reviewed with each individual resident. Decisions made relating to the home are discussed and agreed by all residents at the house meetings these include decoration of the home, meals provided and venues for group activities. One resident advised that the home had received a donation; the decision as to how this money was to be spent will be made at the next residents meeting. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 11, 12, 15 and 16 The provision of additional staffing will enable the home to support all of the residents to participate fully with rehabilitation, occupation and to develop their independence. While the use of public transport can be seen as a positive move, without additional staffing, this could further limit resident’s opportunities. The residents are supported to maintain family links and friendships. EVIDENCE: Standards 13 and 17 were met at the last inspection and were not inspected on this occasion. Examination of the staffing rotas confirmed that there is still insufficient staffing to enable the residents to have an increased opportunity to participate in activities that will promote their independence, provide opportunities for rehabilitation and to increase leisure opportunities. Records relating to the residents meetings identify that some planned activities had been cancelled due to staffing shortages. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 13 The manager advised that in the future the home will not have its own transport, residents will be required to use public transport and taxis. Risk assessments and risk management strategies relating to the residents accessing the kitchen have been reviewed. The residents were observed to have free access to the kitchen and were able to make themselves drinks throughout the inspection. It was also noted at the last inspection that the bathroom door on the ground floor was locked, restricting the resident’s access. During this inspection the residents were observed to have free access to all communal areas of the home. Discussions with the staff and residents confirmed that the residents are supported to maintain links with their families and friends, if they wish. If required the home provides support with writing letters and using the telephone. Visitors are welcome in the home. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 18 The residents are supported in a sensitive way that reflects their personal preferences and assessed needs. The resident’s needs are not best served by the clinical room having much of its limited space taken up by non clinical items. EVIDENCE: Standards 19 and 20 were met at the last inspection of the home and were not assessed on this occasion. During the inspection the staff were observed to support the residents in a sensitive way that promotes their privacy and dignity. The level of support required to assist the residents to attend to their personal care needs is recorded in individual care plans. These are agreed with the residents. Observations during the inspection confirmed that the level of care provided reflects that which had been agreed. It was noted at the last inspection that the home has a very small clinical room. Space is limited and the work surfaces are cluttered. This room is also used for the storage of the residents cigarettes, residents monies and staff post . This detracts from the purpose of the room and may hinder the nurse’s ability to respond to the residents nursing and medical needs effectively. This situation remains unchanged. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 22 and 23 The home has a satisfactory complaints procedure in place, the residents are provided with sufficient forums in which to raise concerns or make complaints. The homes policies and procedures protect the residents from abuse. EVIDENCE: The residents confirmed that they are aware of the homes complaints procedure and are confident that concerns raised or complaints made will be addressed by the home. Residents can raise concerns or make complaints on an adhoc basis, at residents meetings or as part of the regular 1:1 meetings held with their keyworker. The complaints procedure is available in the home. Information provided in the Pre-inspection questionnaire indicates that the home has not received any complaints. This could not be verified, as the manager could not locate the complaints log during the inspection. The manager demonstrated in discussion that acceptable procedures would be followed in the event of suspected abuse. An adult protection policy is available in the home. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 24 and 30 Despite the improvements made to the standard of the environment, there are still shortcomings in respect of fire safety, and furnishing and maintenance. EVIDENCE: Issues of serious concern identified at the last inspection have been addressed by the home. Ten requirements were made at the last inspection in relation to the environment. Three of these have been met in full; three are met in part. A tour of the home and discussions with the residents confirmed that the home is now maintained at a comfortable temperature. A lock has been provided to the ground floor bathroom, which has an override facility to be used in the event of an emergency. Communal areas of the home have recently been decorated. The residents said that this has made a big improvement to the overall appearance of the home. They confirmed that they were consulted in choosing the new colour scheme. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 17 The overall cleanliness of the home has improved. The residents stated that they all take responsibility for cleaning the communal areas of the home. Care plans are in place to support the residents who require additional support to maintain the cleanliness of their own bedrooms. This work is ongoing. The home was required to complete risk assessments and develop risk management strategies with regard to the residents smoking in their bedrooms and in bathrooms. These have been completed, however as detailed earlier in this report the strategies currently in place are not effective. Although it was not observed during this inspection there is evidence that the residents continue to smoke in their bedrooms. It was noted that curtains were missing from windows in one residents bedroom, these have now been provided but it is noted that the blind in the first floor shower room is missing and there are no curtains at one lounge window. The home was required to maintain windows to enable the residents to keep them open if they wished, and to repair or replace rotten window frames. This work has not been completed. The sofas in the small lounge have also not been repaired or replaced. The requirement made for the home to continue with the plan in place to refurbish the kitchen to an acceptable standard remains outstanding. The manager stated that an Environmental Health Officer had made an inspection of the kitchen in the week prior to this inspection and intended to serve an improvement notice on the home with regard to this. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 18 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 The current staffing ratios, recruitment practices, lack of provision of mandatory training and the skill mix of staff rostered to work in the home restrict the ability of the home to ensure that the residents are effectively and safely supported. EVIDENCE: 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. It has been noted at previous inspections that these staffing ratios are not sufficient to support the residents with rehabilitation, occupation and to develop independence. The requirement made at the previous three inspections to provide sufficient staffing to support these activities remains outstanding. Since the last inspection the home has recruited new staff members and now does not have any staffing vacancies. The two staff members on duty at the time of the inspection, confirmed that they had been employed in the home for a very short time, the nurse in charge had worked four shifts, this being the first day that she was left ‘in charge’ in the home and the member of care staff had worked five shifts. The care staff member stated that she had not yet had chance to read or familiarise herself with the residents care plans. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 19 The recruitment files relating to these staff members were examined. These contained evidence that the required information as detailed in Schedule 2 of the Care Homes Regulations 2001, has been obtained with copies retained on the individuals file. This is with the exception of the provision of an enhanced Criminal Records Bureau check (CRB), for one staff member a standard check had been completed. A Protection Of Vulnerable Adults (POVA) check has been completed for both staff members. Training records provided as part of the homes pre-inspection questionnaire confirmed that the staff team have been provided with some training that is relevant to their role. However the records provided indicated that not all staff members have completed mandatory training in relation to fire, food hygiene, adult protection and first aid. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 20 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The residents cannot yet be confident that their views underpin the future development of the home. The home has taken some action to promote the health and safety of the residents and staff this is not sufficient to ensure safety is maintained. EVIDENCE: Since the last inspection the organisation has undertaken an audit of the quality of service provided in the home. A report relating to this is available. The manager stated that there is a plan in place to complete a service review that will seek the views of the residents and their relatives. Documentation relating to this was available in the home. The requirements made at the last inspection in relation to health and safety have been met in part. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 21 Certificates are available to confirm the safety of portable electrical appliances and gas equipment. Risk assessments relating to safe working practices have been reviewed. An automatic door closing device has been fitted to the door separating the laundry and small lounge. As noted earlier in the report risk assessments have been completed and restrictions agreed with residents with regard to smoking in designated areas. Evidence within the home questions the effectiveness of these. It is also noted earlier in this report that the Environmental Health Officer intends to issue an improvement notice in relation to the facilities provided in the kitchen. The homes manager is currently employed to work in the home on a temporary basis. Whilst it is acknowledged that she has undertaken considerable work to meet the requirements made at the last inspection and has demonstrated her commitment to the home, the organisation must recruit a permanent manager for the home. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 2 12 2 13 X 14 X 15 3 16 2 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x x x 2 X 2 X X 1 x Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 23 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 YA24YA42YA9 Regulation 12(1) 13(4) 15 23(4)(a) Requirement The provider must ensure that the residents risk assessments and related care plans, with specific regard to smoking, are reviewed and updated and read by staff. Sufficient staffing is to be provided to enable the residents to have an increased opportunity to participate in rehabilitation, independence promoting activities and access to leisure opportunities. This requirement has been made at the previous 3 inspections of this home and remains outstanding. Timescale for action 31/03/06 2 YA33YA11YA12YA16 12(1)(b) 18(1)(a) 31/05/06 Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 24 3 4 YA22 YA30YA24 22(8) 16(2)(k) The provider must ensure 31/03/06 that the complaints log is available for inspection. The provider must ensure 30/04/06 that all areas of the home are clean. This requirement was made at the last inspection – the home has made good progress towards meeting this requirement. The provider must ensure that curtains/ blinds are fitted where these are missing. This requirement was made at the last inspection and is met in part. The provider must ensure that windows are maintained to enable them to remain open if required. 5 YA24 23(2)(c ) 30/05/06 6 YA24 23(2)(b) 30/05/06 7 YA24 23(2)(b) This requirement was made at the last inspection and remains outstanding. The provider must ensure 30/05/06 that rotten window frames are repaired or replaced. This requirement was made at the last inspection and remains outstanding. Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 25 8 YA24 23(2)(c) The provider must ensure that the sofas in the small lounge are repaired or replaced. 30/05/06 9 YA42YA24YA30 23(2)(b) 23(5) This requirement was made at the last inspection and remains outstanding. The kitchen must be 31/03/06 refurbished to an acceptable standard. This requirement was made at the last inspection and remains outstanding. 10 YA32 11 YA34 12 YA35 13 YA37 The provider must provide confirmation of the timescales for the completion of this work as part of the action plan to this report. 18(1)(a) The provider must ensure that all new staff complete a comprehensive induction to the home before they are left to work unsupervised. Sch 2 The provider must ensure that all staff members have a satisfactory enhanced CRB disclosure. 18(1)(c)(i) The provider must ensure that all staff complete mandatory training at appropriate intervals. 8 The provider must recruit a permanent manager for the home and make an application to register this manager with the Commission for Social Care Inspection. 31/03/06 30/04/06 31/05/06 30/04/06 Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 26 14 YA39 24(3) The provider must ensure that the residents and their relatives/ representatives are given the opportunity to express their views as to the quality of service that is provided in the home. 30/05/06 Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations The clinical room should not be used as storage for other items. This recommendation was made at the last inspection of this home. The manager should make suitable arrangements for the disposal of medications. This recommendation was made at the last inspection of this home. 2 YA20 Thistley Lodge DS0000004412.V282595.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Leamington Spa Office 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 DS0000004412.V282595.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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