Inspection on 14/09/06 for Thompson Court

This inspection was carried out on 14th September 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 but made no statutory requirements on the home.

Other inspections for this house

Thompson Court 14/09/07

Thompson Court 01/12/05

Thompson Court 31/05/05

Thompson Court 02/02/05

Thompson Court 21/04/04

Similar services:

Snydale Care Home

Abbey The

Whiteley House

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Thompson Court Morton Lane Crossflatts Bingley BD16 2EP Lead Inspector Liz Cuddington Unannounced Inspection 14th September 2006 12:00 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 Thompson Court DS0000033518.V302480.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. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thompson Court Address Morton Lane Crossflatts Bingley BD16 2EP 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) 01274 561965 01274 563786 City of Bradford Metropolitan District Council Department of Social Services Mrs Miriam Dunn Care Home 37 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (37), Physical disability (8) Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for MD is specifically for the named service user. Date of last inspection 1st December 2005 Brief Description of the Service: Thompson Court is a Bradford Local Authority purpose built resource centre, situated in the Crossflatts area, very close to bus routes and adjacent to the main road to Keighley, Bingley and Skipton. The area surrounding the home is predominantly residential, within easy walking distance of a railway station. The home has a small car park and there is parking on the roadside. Thompson Court is a single storey building offering single room accommodation in one of four wings. Two wings offer bed-sitting rooms; the others have shared lounge and dining areas. Twenty of the thirty-seven bedrooms have en-suite facilities. There are attractive gardens surrounding the home. The home provides personal and residential care for 1 service user who receives permanent care. There are 8 rehabilitation places, where the stay is usually no longer than 6 weeks. The home has 2 ‘step down’ places, with priority given to Airedale Hospital discharges, to accommodate people who would otherwise have to stay in hospital for longer. There are 2 social assessment places, to reduce the need for crisis intervention at home, and 24 places for respite, rotational and short stay care. There is also a day centre with twenty places available from Monday to Friday. Day care services are not regulated. The fees vary depending upon the payment conditions of whichever service the person is using. There is no fee for people referred for rehabilitation under the intermediate care regulations. The full fee for one week’s respite stay is £435.68, but the amount paid depends upon the person’s individual circumstances. Hairdressing, chiropody and newspapers are charged individually. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group, for example ‘Choice of Home’, and ‘Health and Personal Care’. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers these outcomes to the people who use the service. The judgement categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded in the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk One inspector carried out the site visit over two days, which lasted a total of eight hours. The methods I used to gather information included conversations with residents and staff, case tracking, examining records and touring the home. I also sent out questionnaires for residents and their relatives to complete. The purpose of this inspection was to assess a selection of the National Minimum Standards for Care Homes for Older People. I looked at twenty-seven of the thirty-eight standards. Six requirements and four good practice recommendations have been made following this inspection. Although there are still areas for improvement the home has made significant progress since the last inspection. I would like to thank the ladies and gentlemen who were staying at Thompson Court, and all the staff, for their welcome and hospitality during the inspection. What the service does well: Thompson Court provides a complex and diverse service, with around 1,000 admissions and discharges each year. Despite this the atmosphere at the home was calm and relaxed and everyone, service users and visitors alike, were given the time and attention they needed. During the inspection I observed that the staff treat service users with respect and consideration and people’s privacy and dignity was maintained. One service user commented on how good the staff are at communicating with each other if a problem arises. One relative complimented the staff on the “excellent” care they had taken of her relative when he was ill. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 6 The ladies and gentlemen who use the services at Thompson Court spend their time as they choose. I spoke to a number of people, who all told me how much they enjoy their stay at Thompson Court. They said there are activities available which are interesting and varied. The menus are varied with a choice of main courses and desserts at lunchtime and a range of foods available at tea and supper times. The people I spoke to all said that they enjoy their meals. In one of the questionnaires a service user commented that the meals are “Very, very good. Always nice and hot”. The rehabilitation unit has the necessary facilities and trained staff to provide this service. The other units are properly equipped to provide the facilities the service users need. About 70 of care staff have a recognised care qualification. Residents and relatives are aware of how to make a complaint. The home has suitable adult protection policies and procedures. The house and grounds are well maintained, attractive and accessible. There are suitable adaptations fitted to assist people to maintain their independence. The bedrooms are well furnished and service users are welcome to bring personal items with them to make their room more homely. The whole house is clean and hygienically maintained. Infection control measures are in place. On the questionnaires, people confirmed that the home is kept fresh and clean. One service user commented that Thompson Court ‘Feels and smells more like a hotel’. What has improved since the last inspection? What they could do better: Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 7 Despite repeated requirements from the last three inspections there are still no contracts specifying the arrangements for their stay for any of the people who use the service, except for the one permanent service user. There was no evidence to show that the service users or their representatives had been involved in developing and reviewing their care plans. The medication administration systems in place are not being followed properly and safely. The medicine trolley was locked but was not attached to a wall, or safely stored inside a locked room. Confirmation of a satisfactory POVA register check should be sent to the home’s manager before a new member of staff begins work. The training records kept at the home need development, in order to reflect the range of training the staff have taken. A service as diverse, complex and busy as Thompson Court needs a manager whose working day is spent managing the service, not covering shifts as at present. The quality assurance systems are progressing but still need further development. Two of the storage cupboards containing cleaning products, had been left unlocked on the first day of the inspection. 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. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using the available evidence, including a visit to the service. The Statement of Purpose and Service Users’ Guide are available in the home. Relevant pre-admission assessments are made and kept with the care plan files. Bradford Social Services have not yet produced a service users’ contract. The rehabilitation unit has the necessary facilities and staff to provide this service. EVIDENCE: The Statement of Purpose and Service Users’ Guide are available in the main entrance hall and copies are normally left in service users bedrooms. Despite repeated requirements from the last three inspections there are still no contracts for any of the people who use the service, except for the one Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 10 permanent service user. It is the responsibility of Bradford Social Services to provide these contracts. On the first day of the inspection the manager was out visiting a prospective service user, to assess whether Thompson Court could meet their needs. The manager now carries out a pre-admission assessment for each newly referred service user. A Social Services pre-admission assessment is also carried out before someone goes to stay there for the first time. The rehabilitation unit has a dedicated wing of the home. There is a rehabilitation room and physiotherapists and occupational therapists from the healthcare trust work with the service users to help them regain their independence. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using the available evidence, including a visit to the service. The care plans contain all the relevant information but did not show whether service users had been involved in developing them. The medication administration system needs to be improved to make it safe and clear. Staff treat service users with respect and consideration. EVIDENCE: I looked at a number of care plans. They showed in detail how each person’s care was to be provided. There were assessments in place for various areas of care such as falls, moving and handling, continence, pressure areas and mental health. The healthcare needs were well recorded and comprehensive. The details included people’s nutritional needs and any specialist healthcare that was needed. Daily records are kept. Some, such as those on the rehabilitation wing, were more informative than others. Although the plans are kept under review there Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 12 was no evidence to show that the service user or their representative had been involved in developing and reviewing their plan. The medication administration record (MAR) charts, and checks of medicines in stock against numbers administered, showed that the systems in place are not being followed accurately. The charts should be signed each time a dose of medicine is offered and an explanation noted if the medicine is refused or not given. There were signatures missing and, in some cases, ticks and crosses instead of signatures or explanatory codes. I checked nine samples of medication and found inaccuracies or omissions in eight of the samples. Most of the solid medication numbers did not tally with the amounts received and the numbers administered. Some medicines had been received and not recorded on the MAR charts. The ‘brought forward’ system was not completed in every case. I saw a risk assessment for self-administration of medicines in one person’s care plan, although the MAR charts did not always make it clear whether the staff or service user was administering the medication. The medicine trolley was left out in one dining room. It was locked but was not securely attached to a wall. Medicine trolleys should either be attached to a wall or stored inside a locked room when not in use. Some medicine administration instructions were still written using the Latin terminology. For clarity this information should be in English. I saw notes in the care plans showing the name each service user prefers to be called by. During the two days of the inspection I observed that the staff treat service users with respect and consideration and privacy and dignity was maintained. The service users I spoke to said the staff are respectful and considerate. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using the available evidence, including a visit to the service. People are able to choose how they spend their time. A range of activities is available. Support for people to manage their finances, and information about advocacy services is available. The meals are of a high standard and mealtimes are relaxed. EVIDENCE: I spoke to several service users, who all told me how much they enjoy their stay at Thompson Court. They said there are activities available which are interesting and varied. One lady showed me an example of some craftwork she had done with the co-ordinator. They all said how good the activities coordinator is and described some of the activities which are arranged for them. If they wish, service users can also go to the day centre and take part in the activities there. From people’s comments to me, and in the returned questionnaires, it was clear that the ladies and gentlemen who use the services at Thompson Court can spend their time as they choose. My own observations also confirmed this. Some of the bedrooms are bed-sitting rooms; convenient for people who prefer to spend time following their own interests. Two wings of the home have Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 14 comfortable lounges and there are other seating areas where people get together to socialise. I also saw visitors being welcomed into the home. If help is needed, service users are supported to continue to manage their own finances. There is information in the home about advocacy services for service users and relatives. The mealtimes were relaxed and, where people eat together in the dining rooms, they were sociable occasions. The menus are varied with a choice of main courses and desserts at lunchtime and a range of foods available at teatime. There is also a wide choice of food at suppertime. If a service user does not like any of the choices then the cook will prepare an alternative dish. Drinks and snacks are always available. The people I spoke to said the meals are very good. The people who completed the questionnaires I sent out also said they either always, or usually, liked the meals. One person commented that the daily use of fresh produce makes a difference. Another person confirmed that staff are always willing to make snacks, when asked. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using the available evidence, including a visit to the service. Residents and relatives are aware of how to make a complaint. The home has suitable adult protection policies and procedures. EVIDENCE: The returned questionnaires confirmed that people generally know how to make a complaint if they need to. The people I spoke to also said they would know how to raise any concerns, if they needed to. Bradford Social Services’ complaints policies and procedures are used. I saw copies of the leaflet explaining the process in bedrooms and in the entrance hall. The home has adult protection and ‘whistle-blowing’ policies and procedures in place that cover the way any concerns or allegations of abuse or poor practice would be handled. Protection of Vulnerable Adults training was to be arranged for all staff. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 & 26 Quality in this outcome area is excellent. This judgement has been made using the available evidence, including a visit to the service. The house and grounds are well maintained, attractive and accessible. There are suitable adaptations fitted. The bedrooms are well furnished, the doors can be locked and they all have secure storage spaces. The laundry is clean and well equipped. The whole house is clean and hygienic. EVIDENCE: As this was my first visit to Thompson Court I made a tour of the whole building. The grounds are tidy and attractive and there is a lovely inner courtyard, which the staff have designed and planted as a Japanese style garden. There are tables and chairs as well as attractive plants and trees. Service user commented to me how nice the courtyard is. The grounds and the building are accessible to everyone. The thirty-seven bedrooms are all single rooms; twenty have en suite facilities. Some of the rooms have ceiling mounted track hoists fitted. On the Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 17 rehabilitation wing the tracking in one bedroom goes straight through to one of the main the bathrooms. When that service user is not using the bathroom the connecting doors are locked. There are handrails along the corridors and grab rails in the bathrooms and toilets. Some toilets have raised seats fitted. The doors are wide and the shared parts of the home are spacious. Some of the bedrooms are larger than others and are usually offered to people who need additional space. The bedrooms are well furnished and the doors have locks. Inside each room are a lockable storage drawer and medicine cabinet. Service users are welcome to bring personal items with them to make their room more homely. The laundry is light and spacious and has all the equipment needed. There is a sluice programme on each washing machine. The floor is tiled and the walls can be easily cleaned. The whole house is clean and hygienically maintained. Infection control measures are in place. On the questionnaires, people confirmed that the home is kept fresh and clean. One service user commented that Thompson Court ‘Feels and smells more like a hotel’. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using the available evidence, including a visit to the service. There are sufficient staff on duty to meet the needs of the service users. Staff files contain all the necessary recruitment information; however a satisfactory POVA check must be confirmed before new staff start work, to make sure that service users are protected About 70 of care staff have a recognised qualification. The staff training files need further development. EVIDENCE: The care staff work a three week rota. At present there are vacancies, but recruitment is taking place and the manager is confident that there will be a full staff complement by the end of this year. Until then any vacancies on the rota will continue to be filled by agency staff. Comments I received from service users, in the returned questionnaires and in conversation, said that the staff are either always or usually available. One person said that staff are ‘stretched to the limit, but we have good care’. There are sufficient domestic staff to keep the home clean and hygienic. Two waking night care staff are on duty, but this is soon to increase to three staff. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 19 Thirteen of the eighteen care staff have achieved a National Vocational Qualification (NVQ) in care. All new staff without an NVQ will be expected to take the course. Copies of documents from the main staff files, which are held at Bradford Social Services offices, are now kept at the home. I looked at a sample of six staff files. They all included completed application forms and two written references. The files for staff who had worked at the home for some time showed that satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks had been obtained. The new staff files did not have this information. I was assured that no new staff would start work until a POVA register check had been completed. Then, if the CRB check had not been received, they would work only under the supervision of an experienced staff member. It would be good practice for confirmation of a satisfactory POVA register check to be sent to the home’s manager before a new member of staff begins work. The staff files included information about training that staff had taken. The induction training for new staff was very brief, but the manager said that a new induction training package is being provided by Social Services. New staff take a three day core skills course at the start of their employment. The training records kept at the home need development in order to reflect the range of training the staff have taken, and to show where refresher courses and new training are needed. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using the available evidence, including a visit to the service. The manager has yet to complete the Registered Managers’ Award. The new staffing structures have not been implemented. The manager is still working some shifts and her time available to manage the home is therefore limited. The quality assurance systems are progressing but still need further development. Service users’ finances and any transactions are accurately recorded. Monies are securely stored. Good hygiene and food storage practices are in place. EVIDENCE: The manager is sufficiently experienced to manage the home effectively. She is in the process of completing the NVQ level 4 Registered Managers’ Award. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 21 Until new staffing structures are implemented the manager is still working some shifts, as well as managing the home. A service as diverse, complex and busy as this needs a manager whose working day is spent managing the service, not covering shifts. Individual supervision sessions with the care staff are still not taking place regularly. Staff supervision needs to be implemented as soon as possible. A manager from another Bradford Social Services home visits each year to carry out quality assurance monitoring and a report is written. The home’s manager has carried out a random survey to gain service users’ views over a seven week period this summer. The information has been analysed but the report on the findings has not yet been completed. At present the home does not formally canvass the views of relatives, carers or visiting healthcare professionals. Although many people do, informally, tell the manager and staff what their opinion is of the care and support offered at Thompson Court. Records are kept of the monies that service users leave with the office for safekeeping during their stay, and of any transactions carried out on their behalf. Cleaning materials and toiletries are no longer being left unsecured in the kitchenettes and shared areas of the home. But two of the storage cupboards containing cleaning products had been left unlocked when I toured the home on the first day of the inspection. The crockery and cutlery used on the wings at mealtimes is now being returned to the kitchen to be washed in the dishwasher. This is more hygienic than the former practice of washing up by hand in the kitchenettes on each wing. The home’s main kitchen was very clean and well organised. Refrigerator, deep freezer and hot food temperatures are taken regularly. All refrigerated and frozen foods were properly stored. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 1 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 X 2 Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5 (3) Requirement All service users must be provided with a contract specifying the arrangements made for their stay. This is outstanding from 2/02/05, 31/05/05 and 1/12/05. Service users or their representatives must be involved in developing and reviewing their care plan. The administration of medications must be carried out in accordance with the guidance from the Royal Pharmaceutical Society. Latin terms must not be used on medication records. This is outstanding from 31/5/05 & 1/12/05. The registered provider must demonstrate how the permanent service user will receive any interest applicable to their individual savings. This is outstanding from 31/03/06 Formal documented supervision of care staff must be DS0000033518.V302480.R01.S.doc Timescale for action 31/12/06 2. OP7 15 (2) (c) 31/03/07 3. OP9 13 (2) 31/12/06 4. OP35 20 31/03/07 5. OP36 18 31/03/07 Thompson Court Version 5.2 Page 24 6. OP38 13 (4) (a) implemented and take place at the required intervals. This is outstanding from 31/5/05 & 1/12/05. Cleaning materials must be stored in a secure place. This is outstanding from 31/5/05 & 1/12/05. 30/11/06 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. 4. Refer to Standard OP29 OP30 OP31 OP33 Good Practice Recommendations Information to confirm that POVA checks are satisfactory should be sent to the home before new staff start work. Staff training records would benefit from further development. The home’s manager should complete the Registered Managers’ Award in order to meet this standard. The quality assurance system would benefit from further development. Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Thompson Court DS0000033518.V302480.R01.S.doc Version 5.2 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!