Inspection on 18/01/06 for Thornbank Residential Home

This inspection was carried out on 18th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Thornbank Residential Home 18/12/07

Thornbank Residential Home 19/03/07

Thornbank Residential Home 11/05/05

Thornbank Residential Home 20/01/05

Thornbank Residential Home 22/09/04

Thornbank Residential Home 18/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Thornbank Residential Home 6 Westerfield Road Ipswich Suffolk IP4 2UJ Lead Inspector Jill Clarke Unannounced Inspection 18th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Thornbank Residential Home DS0000024512.V278813.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 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. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thornbank Residential Home Address 6 Westerfield Road Ipswich Suffolk IP4 2UJ 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) 01473 253346 01473 639218 Greensleeves Homes Trust Mrs P O Hadden Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2005 Brief Description of the Service: Thornbank Residential Home is situated in a pleasant residential area of Ipswich and provides accommodation and care for up to 33 older people. The home is owned and administered by the Greensleeves Homes Trust, a non profit making organisation and looks out onto Christchurch Park. The home is sited within easy reach of Ipswich town centre with all its facilities and resources. The Building has been registered as a care home since 1945 when it was first purchased by the WRVS. In 1995 the neighbouring property was acquired and an extension with a link between the two houses was built. Accommodation is sited on three floors but all are accessible via a passenger or stair lift. The home has 29 rooms for single occupancy and 2 shared rooms all of which benefit from en-suite facilities, which include a washbasin, toilet and shower or bath. Additionally the home has 5 assisted bathrooms, which are located across 3 floors. The home has three communal lounges, a small conservatory and a large dining room. One of the lounges is located on the first floor of the building and is often used for meetings or hairdressing services. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the year and was carried out by two inspectors over a period of approximately 8 hours on a Wednesday in January. During the inspection time was spent talking with several of the residents (9 in private) and 3 visitors to the home. Time was also spent with members of staff, which included the Registered Manager, Deputy Manager, maintenance man, care staff (two in private) laundry assistant and the administrator. Commission for Social Care Inspection (CSCI) feedback cards were sent to the home before the inspection, which gave the opportunity for residents, relatives, visitors and staff to give feedback on how they thought the service was run. Comments were received from 12 residents, 13 relatives/visitors and 16 members of staff and these have been included within the report. An environmental tour of the home was undertaken and this included the dining room, lounges, laundry, and a sample of 2 bathrooms, 1 toilet and 5 bedrooms. Paperwork looked at included pre-admission assessments, care plans, training plans/records, maintenance and fire records, recruitment and medication records. What the service does well: What has improved since the last inspection? Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 6 Parts of the home have recently been redecorated with use of bold colours to tally with fire zones and also to aid residents locate their rooms. New fire doors are in the process of being fitted throughout the home. Monthly reviews of care plans have been introduced. 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. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 7 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 Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 8 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): 1,2,3,4,5 People wanting to move into the home can expect their needs to be fully assessed before admission is agreed. This ensures that the home only admits residents within their registration category, whose care needs they can meet. EVIDENCE: A new resident confirmed that information on the home had been provided for them, a copy of which was seen in their room. Details of fees were seen on the resident’s notice board. A copy of the home’s Statement of Purpose was also displayed. At the last inspection concerns were raised about a resident admitted to the home who was later identified to have dementia. The manager confirmed that this resident had been supported by the home to move to a suitable speciality care setting. The manager said that pre-admission assessments were undertaken for all prospective residents. Copies of assessments were seen in the 4 care plans looked at in detail. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 9 Time spent with a resident confirmed that the manager had visited their home for the purpose of undertaking a pre-admission assessment which identified their needs and enabled the manager to be sure that the home was able to meet these before offering a room. The resident commented that it was a “very nice lady who came to visit” and that “kind advice” had been given. The manager offered 2 weeks respite to the give the prospective resident a chance to see if this was what they wanted. The resident recommended that all residents should try the home in this way first “before deciding to move in permanently” as it gave them a chance to see how the home was run. It was clear that this resident was in control and made all the decisions about moving in. Discussions with a resident confirmed that they had been made aware of the cost of the room before admission. When they later chose to move to a bigger room they were informed of the increased costs involved before the move. A relative visiting the home confirmed the family’s satisfaction with the admission process and subsequent care. The home was chosen after a careful selection process which included reading the information provided and informal visits. “They’ve been really good, excellent.” Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 10 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): 7,8,910 People using the service can expect staff to monitor their care, and respect their privacy and dignity. EVIDENCE: Residents spoken with during the inspection all expressed satisfaction with the overall care provided and 12 out of the 13 comment cards received agreed with this view. The care for 1 resident was fully tracked which included talking to the resident and reading their care plan. The care plan reflected the level of care and support the resident said that they needed. Care plans for 4 residents admitted since the last inspection was viewed in detail. Care plans contained monthly review sheets, which had been signed by the resident and contained developments since the last review. Assessment of the effectiveness of the care plan, resident views and any continuing unmet needs and /or assessed requirements for change. A completed falls assessment was included for one resident with Osteporosis and letters from a hospital specialist. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 11 Some shortfalls were identified in relation to information not always being dated and in one case, the review had been signed by the resident but not the member of staff who had undertaken the review. A contradiction was noted in one care plan where the first statement said that the resident would have her hair done by the home’s hairdresser and the next entry stated that the resident would have their hair done by their own private hairdresser. One resident did not appear to have been weighed on admission. The importance of regular monitoring of weights will be addressed following a raising of staff awareness through the MUST (Malnutrition Universal Screening Tool)) training which the manager told us had been held at the home the day before the inspection. Care plans did not contain clear information on dental or optical health checks although a member of staff confirmed that an outside Optical service visits the home annually. Asked if there was anything in the home they would change, a resident replied “some things could work better”. They went on to say that at meal times, tablets are always given out alphabetically, which resulted in some residents “having to wait” for their medication (if their name was at the end of the alphabet). The resident wondered, “if the staff could give out medication earlier?” This also led to discussions about the possibility of staff giving out medication one table at a time. Staff record on the home’s Medication Administration Records (MAR) charts that they have given residents their medication, and at what time. MAR charts looked at, showed that staff were not always signing these records. Medication is dispensed to the home in ‘blister’ packs every 28 days. Medication, which was not supplied in blister packs, is sent in their original or Pharmacist container. Medication held in 6 of the containers was counted, and checked against the MAR sheets, which identified that 4 of the containers did not hold the correct amount. This raised concerns over staff competency in giving medication as prescribed and keeping accurate records. The home, to ensure the safety of residents, was asked to take immediate action (see requirements section). Staff confirmed that they had received training in the safe dispensing of medication, and time spent with a member of staff showed that they had a good awareness of the different types of medication, and what they were used for. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 12 Controlled medication records were checked against stocks held, and were correct. Good practice was seen with eye preparations, and medicines, which had a short shelf life, being dated when opened. It was suggested, due to the location of the medication cupboard, that regular checks are kept of the temperature of the cupboard, to ensure it does not rise above 25°C. Time spent sitting with residents in their bedrooms confirmed that staff knocked on the door prior to entering, although were not always waiting for a reply from the resident first before entering. All the 12 residents who completed the comment cards agreed that their privacy was respected at the home. Residents spoken with felt that they were left alone if they wanted to be and staff respected their privacy. A visitor to the home confirmed that they were able to visit their relative in private. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 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): 13,14,15 Residents can expect that they will be treated with respect by staff and be supported to exercise choice and control over their lives. Contacts with family, friends and community are encouraged. Meal provision is of a good standard although some issues were raised during the inspection process, which the home are looking to address, especially in relation to hot drink distribution and meal choices. EVIDENCE: Of the 12 comment cards completed by residents 11 confirmed that they felt that staff treated them with respect. All 13 comment cards received from relatives/visitors said that they were welcomed into the home at any time they chose to visit. “Staff always seem friendly and welcoming”. This was confirmed through talking with both residents and their visitors during the inspection. “I find the staff friendly and helpful” was one comment. Parking difficulties, were raised as a problem by one visitor. The home has limited parking both at the front and the rear. Much of the roadside parking, at the front of the home is used by people visiting the town centre. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 14 The manager said that religious services were no longer held at the home due to poor response to these from the residents. A visitor from the Methodist Church comes regularly into the home to see certain residents; also Anglican and Roman Catholic clergy visit to meet the individual religious needs of residents. Some residents are supported to attend outside services of their choice. The Mothers Union hold some of their meetings at the home and one resident is an active member. One resident confirmed that they attended a weekly church luncheon club. A staff member told of the resident who actively supports Ipswich Town Football team, and attends matches where possible. The Activities Co-ordinator on a regular basis holds residents’ meetings. The manager confirmed that the views of residents not able to attend are also sought. Comments on cards completed by 12 of the residents showed that 3 residents sometimes wished that they were more involved in decision making within the home. There was a high level of satisfaction for the activities provided. The hairdresser was present during the inspection, and several residents were making use of this facility in the upstairs lounge. The hairdresser said that she always allowed choice of whether the residents used her services but that she kept a record of those who were regular customers since sometimes they might forget about when their hair was last attended to. CSCI feedback cards were completed by 12 of a possible 33 residents. Of these 6 expressed some dissatisfaction with the food provision. A resident asked about the food said it was “excellent” and that the main courses were “ordered the day before – but not the sweet, take it as it comes.” Other comments ranged from “food is very nice” praising the “homemade cakes” to “varies considerably – some don’t like it at all.” A written comment from a relative stated “They have an excellent cook.” One resident spoken with said that they only had “breakfast in their room if they were ill”, but viewed this positively since it gave an aim to the morning – “to get up and get moving.” Written feedback cards raised concerns over the second meal alternative. This was confirmed by a resident spoken with, who did not feel that a salad was suitable as a second choice – “you want a hot meal and pudding at lunchtime.” 2 residents felt that mince was on the menu a lot. “Only thing is the mince – don’t like mince a lot.” Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 15 Concerns were also raised about sandwiches and the choice of fillings on offer. 2 residents stated that they were buying their own fillings. The manager was aware of their choice in this matter, which included families bringing in their special fillings. The manager said that she tried to ensure that any special requests for fillings were met. One example had been the recent successful sourcing of a regional speciality - pork cheese – missed by a particular resident who came from another area of the country. Copies of 5 week menus were viewed which showed that residents were offered a choice of two sandwich fillings each day. These ranged from marmite and lettuce, sandwich spread, chicken tikka or jam. One resident said that they had a “nice variety of sandwiches,” although they felt that staff did not always know what was in the sandwiches. Another said that sometimes the fillings were “very meagre”, giving the example of the potted meat sandwiches – which “didn’t reach the crust.” The 5-week rotating menu seen showed mince-based dishes – savoury mince, chilli, cottage pie, and lasagne – which were offered no more than twice a week. Each lunchtime, there was one main dessert with an alternative of cheese and biscuits or fresh fruit. One resident raised the concern that hot drinks served in bedrooms could be “luke warm” at times. The manager was made aware of this comment. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 16 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 Residents and their relatives can be confident that concerns will be listened to and acted upon appropriately. EVIDENCE: Time was spent with the manager looking at complaints, which had been received by the home. The complaints book showed that one complaint had been received and dealt with promptly by the manager since the last inspection. Residents and relatives spoken with during the inspection said that they were confident that the manager or deputy would deal with any concerns. One resident said they are “always there –you can talk to them”. They went on to say that “they do listen to your complaints.” Complaints leaflets were readily available beside the register of visitors. Eleven of the 13 comment cards relatives/visitors indicated that they were aware of the homes complaint procedure. Of these 4 had made a complaint and one commented, “The matter was reported to the home manager who dealt with the matter speedily and efficiently.” The home is currently investigating missing monies. The police are involved in this investigation and were present at a special staff meeting during part of the inspection. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 17 Most of the staff have undergone Abuse training within the last year. Training Records were seen and two members of staff confirmed their attendance and knowledge of course content. Of the 16 comment cards completed by staff 15 stated that they had received training in the home’s Abuse policy. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,25,26 People living in the home can expect a well-maintained comfortable and safe environment. EVIDENCE: An environmental tour was undertaken as part of the inspection. The home appeared clean and was odour free. In the dining room some scuffed paintwork and marks on the walls were noted. The manager said that this would be addressed during planned re-decorated work. Several service users were visited in their own rooms, all of which were in good decorative order and were personalised to their satisfaction New shelving was seen in one room in order to accommodate the large collection of music tapes belonging to one resident. One resident had their own mini fridge in the room. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 19 All rooms have en-suite facilities. Two were seen during the tour and each had paper towels, gloves and aprons and grab rails had been fitted to meet the needs of the individual resident. The home benefits from the employment of a full-time maintenance person. Enlarged photographs of by-gone local scenes and events were hanging in the corridors. These form part of reminiscence activities within the home. Written comments from 14 out of 16 staff confirmed that they felt the home has sufficient mobility aids to support the needs of residents. Concerns were raised by a relative on the CSCI comment card prior to inspection, over their next of kin’s bedroom, which they felt was cold at times. Staff spoken with during the inspection pointed out 3 bedrooms, which they needed to monitor due to the location of the rooms, and the sash windows. Time spent with a resident in 1 of these bedrooms confirmed “that they had had problems”, they “have to keep bleeding the radiator and the window has been sealed up”. The room was warm at the time of the visit and the resident raised no concerns. A sample of 4 other bedrooms, which had not been identified by staff to be cold, were checked. Two of the residents were in their bedroom at the time, and confirmed that they were warm enough. One bedroom was found to be a little colder, but discussions with the staff confirmed that the resident liked to open their windows during the daytime. The manager advised that there was a planned programme of window replacement for the home due to commence in the near future. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,30 The home has a comprehensive training and development programme available for staff to prepare them for the work they are to undertake. EVIDENCE: Rotas were examined, and staffing levels were sufficient to meet the individual care needs of residents. The home is staffed by two carers at night although the manager stated that this would always be reviewed according to the needs of residents at that time. A visitor spoken with said “They had someone sit with Mum when she couldn’t sleep”. The staff training file was examined. A comprehensive training matrix has been devised which clearly shows training dates and when updates are due. Mrs Hadden (a qualified nurse) and her Deputy have both completed their Registered Managers Award. New staff attend in-house induction and have a named mentor. This takes place over a period of weeks. Records of mandatory training were seen in the training file. Manual handling is taught by Mrs Hadden, who is a qualified trainer. All staff had attended POVA training apart from any new staff now in post. Additional training offered for staff included: Medication training, Challenging Behaviour, Diabetes care, Dementia training and MUST (Malnutrition Universal Screening Tool) training. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 21 There are 18 staff members undertaking an Infection Control course at present. Their assessor was on site during the inspection. 4 staff members are qualified First Aiders while another 10 have completed the Appointed Persons Course. The home have achieved their ratio of 50 staff qualified to NVQ Level 2 or equivalent and have booked 5 more places on Level 2 courses for 2006. 16 staff members completed CSCI pre-inspection comment cards. Of these 14 confirmed that they felt that they had received sufficient training to undertake their role. One said “I feel that the home is run very well by Pat, the manager. Pat also tries to encourage staff to do more training and is always supportive – but the staff at times don’t seem interested in further development.” Two senior members of care staff were spoken with individually. One said “I can’t fault the support – all are given opportunities and encouraged.” Both confirmed that they had attended mandatory training including POVA, and also Dementia, Bereavement and Medication training. Both said that they were undertaking NVQ level 3 and also the Infection Control distance-learning programme. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35,37,38 The environment of the home is generally safe but there are shortfalls in relation to documenting medication and safe storage of monies, which must be addressed. EVIDENCE: The home has developed a very well organised system for keeping residents’ monies. 4 monies were checked against the records and found to be correct. A similar system of recording and signing out of valuables needs to be devised. The box containing the residents monies held for safe keeping, although locked, was found to be stored in an unlocked cupboard. The key cabinet was also found to be unlocked, therefore accessible to people entering the office. Medications records for 4 residents were found to be incomplete due to lack of signature or code entry. Medication received into the home on behalf of one resident had not been correctly recorded. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 23 Since the last inspection, call bells are no longer lengthened with the aid of string. The manager said that the resident had been issued with a pendant to wear round the neck in order to more safely call for assistance A fire alarm test took place during the inspection as part of a member of staff’s induction. Records of regular tests were seen. Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 3 3 3 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 X 2 3 Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP8O Regulation 13(1) Requirement Care plans must evidence how care needs e.g. optician, dentist and chiropodist are assessed and how these are being met Timescale for action 01/04/06 2 OP9 13(2) Staff must sign (or enter code) to confirm medication has been given to the resident, and that they have taken it. 18/01/06 3 OP9 13(2) The home must ensure that they keep an accurate record of all medication received into the home on behalf of residents 18/01/06 4 OP9 13(2) The home must ensure that staff administer resident’s medication as prescribed by their general practitioner 18/01/06 Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 26 5 OP35 16(2)(1) The home must ensure that resident’s money held for safekeeping is kept secure 18/01/06 6 OP35 17(2) Sch 4 (9) The must ensure that a system of recording valuables for safe keeping is devised 01/03/06 6 OP37 17(1) Sch. 3(3)(i) The home must ensure that medication records are accurately kept 18/01/06 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 Refer to Standard OP15 Good Practice Recommendations The Registered Persons should consider alternative drink distribution to ensure that all drinks given to residents are at an acceptable temperature. The Registered Person should consider reviewing the alternative lunchtime choices in consultation with the residents The Registered Person should consider monitoring residents bedrooms in the evenings, to ensure where residents have opened the windows during the day time, that the bedroom is of a comfortable heat. 2 OP15 OP25 3 Thornbank Residential Home DS0000024512.V278813.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. 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