Inspection on 30/11/05 for Thornbury Care Centre

This inspection was carried out on 30th November 2005.

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

Thornbury Care Centre 28/05/09

Thornbury Care Centre 09/11/07

Thornbury Care Centre 26/02/07

Thornbury Care Centre 15/08/06

Thornbury Care Centre 28/06/05

Thornbury Care Centre 23/03/05

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Thornbury Care Centre 58 Thorndale Road Thorney Close Sunderland SR3 4JG Lead Inspector Miss Nic Shaw Unannounced Inspection 30th November 2005 08:30a 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 Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 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. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thornbury Care Centre Address 58 Thorndale Road Thorney Close Sunderland SR3 4JG 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) 0191 5201881 European Care (England) Ltd Care Home 44 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (23), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (6), Old age, not falling within any other category (21), Physical disability (2), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (6) Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Thornbury Care Centre is a three story building situated in the centre of Thorney Close. The home is registered for up to 44 people, 23 of whom have a dementia type illness. Nursing care is not provided but District Nursing services are accessed as required. The home is built on a sloping sight with accommodation for residents over two floors with a service area on the lower ground floor. Accommodation consists of a lounge and dining room and bathrom on each floor. A passenger lift serves the first floor, which specifically provides accommodation for people with dementia care needs. All bedrooms are single occupancy and each benefits from en-suite shower and toilet facilities. The home has been specifically designed to provide accommodation for people who have a physical disability. There is a spacious garden to the rear of the home and a car parking facility is provided adjacent to the home. The home is situated close to local shops, pubs, places of worship and a community centre. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 8.5 hours in November 2005 and was a scheduled unannounced inspection. Due to the size of the home the inspection involved two inspectors. The inspection process involved spending time talking to approximately 20 residents, 3 visitors and 7 staff, including domestic staff. A sample of records were examined including care plans, rotas, staff training records and quality assurance processes. A tour of the building took place which included all communal areas and a sample of residents bedrooms. The judgements made are based on the evidence available on the day of the inspection. The manager stated the people who live in the home prefer to be referred to as residents and this will be reflected throughout the report. What the service does well: The home offers the residents a clean, homely environment in which to live. All bedrooms benefit from en-suite shower and WC’s which promotes privacy and dignity. The residents benefit from a well managed home, with an experienced manager, who is open and approachable and who demonstrates a strong sense of leadership. The manager makes sure that she carries out a needs assessment with all prospective residents so she can be assured that the home is appropriate for them. The staff are polite and courteous to the residents and always ensure that they are afforded with privacy and dignity. Relatives and residents said that they felt their health care needs are adequately met in the home. There is a strong commitment to staff training and in addition to NVQ training in care, staff have completed in-depth training in the needs of people with dementia. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The manager needs to find out if any of the people accommodated on the ground floor have a dementia type illness in order to ensure that people are appropriately placed. Care plans need to be developed so that staff are provided with clear guidance on what to do to meet the residents needs. Medication administration procedures need to be improved. For example: staff should not handle medication as this may cause contamination. Although there have been improvements in the area of activities there is still the need to provide the residents with an activities programme. Residents should be consulted with the development of this. All of the residents bedrooms are kept locked on the first floor of the building. This may prevent some of the residents from using their bedroom during the day and must be reviewed. The complaints procedure needs to be provided in a format suitable to those people who have a visual impairment. The homes adult policy and procedure needs to be amended so that staff know that they must report all suspected abuse to the Local Authority. A designated smoking area within the home needs to be agreed and this should involve consultation with the residents. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 7 There were a number of potential hazards which could compromise the health and safety of the residents observed on the day of the inspection: For example: fire doors being wedged open, free standing radiators, which could pose a potential trip hazard, and bathwater temperatures not being maintained at 43 degrees centigrade, which is the recommended safe temperature. The manager needs to introduce ways of obtaining feedback from the residents so that they can help to influence the development of the service. 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. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 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 Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 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): 3&4 Each resident’s needs are assessed prior to their move to the home. This helps to ensure that their needs are met at the home and inappropriate admissions are avoided. Some of the residents who are accommodated on the ground floor still need to be re-assessed so that they can be assured that their care needs are met effectively. EVIDENCE: Each resident has a social worker’s assessment undertaken prior to their admission to the home. The manager also carries out an individual assessment to ensure that the home is suitable for meeting the needs of residents who are accommodated there. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 10 Observations during the inspection indicated that there continue to be a small number of residents who are accommodated on the ground floor who have some short-term memory loss. Discussion with the manager confirmed that this is an area where the home has recognised the need for re-assessment of need. Meanwhile the feeling amongst some residents remains that there are people wrongly placed on the ground floor who should be accommodated on the first floor. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 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 The health and personal care needs recorded in the care plans do not reflect the resident’s current level of need. Some of the medication administration procedures are unsafe. This potentially means that the resident’s health and personal needs are not being adequately met and therefore their welfare is at risk. Arrangements are in place to help preserve resident’s privacy and dignity. EVIDENCE: As has been reported during previous inspections care planning continues to be a shortfall. A new standardised care plan format is currently being introduced, however, from the sample of care plans examined there was insufficient information available to provide staff with clear step by step guidance of the action needed of them to meet the residents assessed needs, particularly for those residents who have a dementia type illness. This has been an on-going issue of concern discussed during previous inspections and must be addressed by the manager. Nevertheless, residents and relatives spoke positively of the staff and confirmed that the health care needs of the resident’s were adequately met in Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 12 the home. A record of contact with GP’s, District Nurse and other health care professionals is maintained. The home encourages people to look after their own medication where they are capable of doing so, and those people know how to keep their medication securely stored. However, most people have their medication managed by the staff. Staff who are responsible for looking after the medication have had training in this area. Medication is delivered to the home by a pharmacist, mainly in a monitored dosage system. Medication is stored securely in locked cupboards on both floors. Medication records include the name, medication type and a recent photograph of each resident, so that staff know who the medication is for. During this visit, a member of staff handled the tablets before putting them into a pot to take to the residents. This can contaminate the medication. Records of medication given were signed before the tablets were actually taken to the resident. This is not good practise as the resident might not take their medication for any number of reasons. Records of medication not given, because a resident was in hospital, had two different types of codes, one of which must be incorrect for this medication system. It was clear from observations and discussions that residents are treated with respect and dignity, and that any personal support is provided in the privacy of their own rooms or in bathrooms. There is a portable telephone so that residents can make and receive calls in the privacy of their bedroom. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 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 Residents opportunities for activities and leisure events are improving. Residents are able to maintain contact with family and friends and the local community, however not all residents are helped to exercise control and choice over their lifestyles and therefore their right independence may be compromised. EVIDENCE: Since the last inspection a part-time activities co-ordinator has been appointed, and some activities are now taking place. Recent events have included a clothes party, a social night at a neighbouring community centre, a Halloween Party and lunch out at a local pub. Some residents spoke about the increase in the number of social events, but commented that there are still few day time activities. There is no activities programme in place yet for residents information, although social events such as parties are advertised in the monthly newsletters. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 14 The activities co-ordinator said that they are currently looking at residents responses to different activities, as they occur, to see which ones people prefer. Care staff have recently completed training in dementia care and they are using this to find out about individual residents preferred lifestyles, including any interest in activities. In this way the home hopes to improve the daily lifestyle and leisure opportunities for the people who live here. There was a steady stream of visitors to the home on the day of the inspection and they stated that they are made to feel welcome in the home. Relatives had many positive comments to make about the kind staff, lovely rooms and very good food. Staff were seen to be courteous and approachable in their contact with relatives. Some residents go out with relatives. Some residents have had the opportunity of going to a local community centre and to lunch at a local pub. There are a few shops next to the home that residents use with staff support and in these ways most residents still have links with the local community. It was clear that residents accommodated on the ground floor are able to continue their own preferred daily routines and to make their own choices about how they spend their day. In this area of the home some people enjoy spending time in the privacy of their own rooms as well as some time socialising in lounges. One resident said that they had chosen, on this day, to have their lunch in a lounge whilst watching TV. Staff were supportive of this choice, ensuring that the resident had a tray and drinks nearby, and the remote control for the TV. Residents on the first floor have a choice of two lounges and a dining room in which to spend their day but are not able to access their own bedrooms. Bedrooms are kept locked but there are no individual risk assessments in place to indicate why residents cannot access their own rooms. Also there is no supportive signage for most residents to know which is their room. One resident spent all afternoon asleep in a chair in a busy lounge, but was not offered the choice of spending time in their own room. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 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 The home has a satisfactory complaints system. Complaints are handled appropriately and the outcomes used to improve the service. However, the complaints procedure is not available in a format suitable for those people who have a visual impairment, which may prevent some of the residents from expressing their views. Policies and procedures are in place, however minor amendments need to be made to these to fully protect residents from abuse and potential harm. EVIDENCE: The home has a complaints procedure, which is available to the residents in the Service User Guide. It is on display in the residents bedrooms, however, in order to meet the requirement of regulation 22(6) this document must be made available in a suitable format for those residents who have a visual impairment, as currently it is only available in small print. There has been one complaint made to the manager since the last inspection. An examination of the complaints record concluded that the manager had dealt with this appropriately. However, in discussion with the manager it was evident that on a day to day basis she deals with “gripes and concerns” raised by relatives and residents. Advice was offered that a record of these, together with action the manager has taken to address them, should be maintained as further evidence that residents views are listened to and acted upon. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 16 Records examined and discussion with staff confirmed that staff have received “basic abuse awareness” training. Sunderland’s Local Authority MAPPVA, (Multi-Agency Panel For the Protection of Vulnerable Adults), has also been discussed with the staff during staff meetings and information was available in relation to who the “Alerter”, “Responsible Individual” and “Lead Officer” are within the organisation. However, policies and procedures in relation to prevention of abuse do not clearly state that all suspected abuse must be reported to the Local Authority. This issue was raised during the last inspection. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 17 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): 20, 21 & 26 Residents have access to a good range of lounges and there are sufficient showering and toilet facilities. However, designated smoking areas have not been agreed, and bathwater temperatures are very low, which could compromise the health and safety of the residents. The home is clean and hygienic. EVIDENCE: There is a good range of lounge and sitting areas on both floors. However, several residents and their visitors are not happy with the arrangements for the small number of residents who smoke. On the ground floor residents who wish to smoke are asked to do so in the dining room, but not at mealtimes. On the first floor residents are taken to the larger lounge to smoke. However, this room is also used by residents and their visitors, some of whom said that they find smoke offensive and a risk to their health. They are unable to use Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 18 the smaller lounge, as it is constantly full. Residents and visitors said that they have not been consulted about designated smoking areas, and the homes Statement of Purpose does not make reference to this. In this way the home cannot guarantee smoke-free sitting areas for some residents and visitors. All the bedrooms have an en-suite shower and toilet and as such residents can enjoy private washing and showering facilities, which supports their dignity and privacy. However, in two en-suites the shower curtains were missing. There are also two communal bathrooms, (one on each floor), so that residents who choose to can have a bath. However, the layout of the bathrooms means that there is not much room for staff or residents to use the chair hoist. Records of the temperature of hot water to the bath on the first floor are recorded from time to time but the water was very cool on the day of this visit and too tepid to bathe in. There are four communal WCs, (two on each floor), near to lounges for residents and visitors. There were staff instruction notices in both WCs that referred to continence pads, which compromised the dignity of the people who live in the home. Also the lock to one much used toilet on the ground floor was broken, which does not support the privacy of anyone using this facility. The areas of the home that were examined during this visit were clean and hygienic. Residents and their visitors had many positive comments to make about the quality of accommodation, including the cleanliness. The small laundry area is on the lower ground floor away from residents accommodation. The laundry room is well equipped, but the ironing board cover is now perished and needs to be replaced. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 19 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 & 30 The deployment and number of staff on all shifts ensures that at all times residents are supported by an experienced group of staff. EVIDENCE: On duty at the time of the inspection were 6 care staff one of whom was the senior in charge. This is consistent with the minimum staffing levels and a sample of previous rotas viewed confirmed that this has been maintained. Observations during the lunchtime period indicated that those residents on the first floor, due to their needs in relation to dementia, would benefit from additional staff support. Discussion with the manager indicated that she was currently in the process of reviewing staffing levels, and the deployment of staff over busy periods, in order to address these issues. As well as the NVQ level 2 qualification in care, which 13 staff have completed, 10 of the staff have completed in-depth training in dementia care, and as mentioned earlier in the report, as a result of this have started to implement “life story” work with the residents. Other training for staff has involved “advanced care practices”, which includes topics such as communication and “client independence”. Staff were noted to spend quality time with residents, listening to their opinions and experiences and taking part in discussions and demonstrating good humour. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 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 & 38 The resident’s health and safety is promoted by a well managed home and robust procedures are in place to safeguard the residents finances. However, there are some areas of potential risk to resident’s safety, which need to be addressed. The systems for resident’s consultation in the home are inadequate with no formal processes in place to obtain the residents views. This needs to improve to promote and safeguard residents’ rights. EVIDENCE: Residents and visitors spoken to said that the manager often consults them about the service provided. They said they knew who the manager was and said they felt they could approach her and the staff with any concerns they may have. However, although the company have formal quality assurance systems in place to obtain the views of residents, such as questionnaires, Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 21 these have not been implemented in the last year and the manager agreed that this is an area for future development. The current manager has a number of years experience in management and has now submitted her application to become the registered manager, which is currently being processed by the Commission for Social Care Inspection. From observations and discussions, it is evident that the manager is sufficiently competent and skilled to carry out this role and has demonstrated the capacity to undertake additional training in order to update and expand her experience by completing training in the needs of people with dementia as well as NVQ level 4. There are clear lines of accountability within the home. A sample of residents personal allowance records maintained by the home were examined. For each purchase made by the staff, on behalf of the residents, receipts and two staff signatures are maintained. Where the residents are able they are encouraged to sign the cash transaction sheet themselves. Secure facilities are provided for the safe-keeping of money and valuables on behalf of the residents. On the day of the inspection a number of practices were observed which could compromise the health and safety of the residents: • The alarm cords in one bathroom, WCs and some en-suites were tied up out of reach so staff or residents could not summons assistance in an emergency. The wardrobe in one bedroom was no longer fixed to the wall, (although it had been previously), and this could cause a hazard to the resident and staff if it overbalanced. The door to one bedroom was propped open with a small piece of furniture because the resident wanted to keep their door open. However, this compromises fire safety in this area of the home. The two kitchen doors were also propped open even though catering staff were in a different room. The kitchen is a significant ignition source so this practice also compromised the fire safety in the home. • • • In addition to the above approximately six bedrooms have been provided with additional heaters to improve the temperature of these rooms during the winter period. As the heaters are free- standing radiators, they could present a tripping hazard to some residents. There were no risk assessments in place in relation to the use of these radiators to demonstrate that they are not a potential hazard to the residents and to ensure that they are sited to minimize the risk of residents falling over them. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 22 These issues were discussed with the manager during the inspection. Discussion with the manager and staff confirmed that staff are provided with training in relation to health and safety matters, such as moving and handling, first aid and fire fighting and this training is kept up-to-date. Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X 2 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 24 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 OP4 Regulation 14(2) Requirement Timescale for action 31/03/06 2 OP7 15 3 OP9 13(2) The manager must ensure that the number of people with dementia care needs is within the homes registered categories, and that the residents increase in dependenecy levels is kept under review.(Timescale not met 31/07/05). Residents care plans must be in 31/03/05 suffiecient detail to guide staff of the action they should take to meet their health and welfare needs.(Timescale not met 30/11/05). Medication must not be touched 30/11/05 by hand before being given to residents; records of medication administered must only be completed after being given; and the correct codes must be used to denote the reason why medication is not taken. 4 OP12 16 A range of activities must be offered to residents and these should be advertised for residents information. DS0000063778.V254017.R01.S.doc 31/03/06 Thornbury Care Centre Version 5.0 Page 25 (Timescale not met 30/06/05). 5 OP14 12(4)a, 13(4)a All residents must have access to 31/03/06 their own bedrooms unless it can be demonstrated through a risk assessment of individual needs that it would be an unreasonable risk for them to do so. The complaints procedure must 31/03/06 be made available in a format suitable to those people who have a visual disability. Residents must be consulted 31/03/06 about appropriate designated smoking areas; any smoking areas must not impact on the health & welfare of others; and any agreed designated areas must be incorporated into the homes policies and Statement of Purpose. Checks of the hot water temperature of both baths must be carried out at least weekly and any adjustments made as necessary to ensure a satisfactory temperature. 30/11/05 6 OP16 22(6) 7 OP20 12(2),12( 3)&13(4) 8 OP21 13(4)(a&b 9 OP21 12(4)a Staff instruction notices must be removed from residents accommodation. Systems must be put in place to obtain the views of residents and their relatives. The lock to the ground floor toilet must be repaired or replaced. Wardrobes must be fixed to the wall to prevent the risk of it falling over and injuring the resident or staff. DS0000063778.V254017.R01.S.doc 31/12/05 10 11 13 OP33 OP21 OP38 24 12(4)a &32(2)c 13(4) 31/03/06 31/12/05 30/11/05 Thornbury Care Centre Version 5.0 Page 26 14 OP38 13(4)a,b,c a)Advice must be sought from ,23(4)a the Fire Authority about the provision of suitable fire safety equipment for residents to use for their bedroom doors. b) The doors to the kitchen must not be propped open. 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP14 OP18 Good Practice Recommendations There should be suitable signage around the home to help residents to find their way around this large building. The home’s adult policy and procedure should be amended to take into account the Local Authority MAPPVA procedures, in that all suspected abuse must be reported to the Local Authority. All en-suite showers should be fitted with shower curtains. Consideration should be given to the layout of the bathrooms to ensure that staff can residents can safely use the lifting equipment. 3 4 OP21 OP21 Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Thornbury Care Centre DS0000063778.V254017.R01.S.doc Version 5.0 Page 28 - 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. 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