Inspection on 20/04/06 for Thornbury Residential Home

This inspection was carried out on 20th April 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

Thornbury Residential Home 27/05/08

Thornbury Residential Home 30/05/07

Thornbury Residential Home 15/11/05

Thornbury Residential Home 12/01/05

Thornbury Residential Home 08/10/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Thornbury Hempstead Road Uckfield East Sussex TN22 1DT Lead Inspector Kevin Whatley Unannounced Inspection 20th April 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 Thornbury DS0000021270.V287030.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. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thornbury Address Hempstead Road Uckfield East Sussex TN22 1DT 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) 01825 765502 01825 769852 Mr John Johnson Mrs Alyson Johnson Mrs Alyson Johnson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of nineteen elderly people to be accommodated (19) Service users must be aged 65 years and over on admission Date of last inspection 15th November 2005 Brief Description of the Service: Thornbury is a residential care home providing personal care and accommodation for 19 older people, being situated in walking distance from the town centre of Uckfield. The registered proprietor has owned and managed the home for over 19 years. The property is a two storey detached house with a stair lift for access between the floors. All service users benefit from single bedrooms, 5 of which have ensuite toilet facilities. There is a pleasant garden at the front of the building that is well maintained with garden furniture available during fine weather. The home also has a patio at the rear of the building, both the garden and patio areas allow easy access for residents. The home is attractively decorated and communal areas comprise of a conservatory leading off from the large main lounge with a separate dining room. The home has 3 communal bathrooms and 3 toilets. As of the 10th May 2006 the accommodation fees at the home range from £337 to £425, with additional costs required for personal toiletries, newspapers and hairdressing. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Thornbury will be referred to as ‘residents’. The unannounced inspection visit took place on a weekday in April being carried out by the Link Inspector for the home and a Pharmacy Inspector. The inspection visit lasted for approximately 7 hours. At the time of the inspection Thornbury was accommodating 18 residents. The Inspection included a tour of the premises, both inside and out, and it’s facilities with many residents agreeing for their bedrooms to be viewed. The Inspector spoke with the proprietor/manager, the deputy manager, a senior carer, two members of care staff and the cook. Approximately five residents were spoken to during the inspection; whilst care staff were observed carrying out their duties. The Pharmacy Inspector focused primarily on reviewing the homes medicine storage and administration procedures and practices. A number of records and documents required by regulation were also seen during the site visit including the accident book, the fire safety record, the complaints book, the medication administration record book and a sample of staff records. In preparing this report it was also necessary to assess and consider additional information concerning Thornbury. Such information was gathered from a number of sources including service history information held at the Commission for Social Care Inspection (CSCI) offices, 6 surveys returned by residents prior to the inspection visit, telephone conversations with a number of the residents relatives/next of kin and telephone conversations with other care professionals who visit or who have contact with residents living at the home, such as Social Workers and District Nurses. This report should be read in conjunction with the previous inspection report dated 15th November 2005. What the service does well: Thornbury ensure that prospective residents and their families/carers have sufficient information concerning the home and the services it offers and enable them to visit and assess the home prior to admission. The home has a relaxed and homely atmosphere and residents have the opportunity to engage in group and individual interests and events, whilst the routines of the day are Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 6 reasonable. The dietary needs of those living at the home are met and residents commented that the food is ‘very good indeed’. The homes environment is well maintained and offers residents a pleasant standard of accommodation. Staff are committed and caring, whilst the manager has 20 years experience of running the home. What has improved since the last inspection? 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. Thornbury DS0000021270.V287030.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 Thornbury DS0000021270.V287030.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 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives/carers have the information they require to enable an informed decision to be made prior to considering moving into Thornbury. Assessments made on prospective residents must detail the medical needs of those moving into the home. EVIDENCE: The homes statement of purpose outlines the services offered at Thornbury including all necessary information including the homes philosophy of care, daily routines and complaints procedures. The information provided also confirms that residents initially move in on a one months trial basis. From the available information it was not clear as to the length of time the home can accommodate a resident for ‘respite care’. The manager acknowledged that ‘respite care’ would be consider any period of time between one day and three weeks. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 9 When residents are admitted to the home they are given a service user guide that summarises the information contained in the statement of purpose, the guide also contains a contract that includes terms and conditions of residency. Three care assessments were viewed notably those of the most recently admitted residents and were found to contain adequate information regarding each resident. These confirmed that the manager had visited them prior to admission to the home and she had subsequently completed written care assessments including addressing their physical, health and social care needs. Care assessments also contained completed risk assessments that identified any concerns regarding the welfare of the resident including risks of falls and mobility issues. However one care assessment was found to contain insufficient information regarding the resident’s medication needs and requirements. Several residents confirmed they had been able to visit the home prior to being admitted, this was also confirmed by a relative who stated they had the opportunity to view the home prior to their relative moving in and understood that the initial period of residency was considered as a trial period thus allowing their relative the option of ‘getting used to their new home’ before deciding if they wish to remain there longer term. The home does not provide intermediate care. Thornbury DS0000021270.V287030.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, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care planning at the home does not contain sufficient guidance for care staff to ensure they are able to meet the individual health care needs of residents. The current system of medicine storage and administration must be improved to ensure that the medical needs of residents are not compromised or placed at risk. EVIDENCE: Three care plans were seen these confirmed that the home incorporate the individual care needs of residents into suitable plans of care that highlight particular care needs such as the physical and social needs of residents with descriptions of how such needs will be met by care staff. Residents are registered with local GP’s and records confirmed that health appointments such as dentist, opticians and chiropodists are arranged when necessary. Care plans are reviewed regularly by the manager or her deputy, though outcomes from such reviews should be added. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 11 As previously noted one care plan did not contain sufficient or accurate information regarding their medication needs. The pharmacist inspector inspected medicine management. It was noted that some positive improvements have been made since the last inspection. A recent concern raised by a relative (see also complaints and protection) identified the need for appropriate management of medicine for residents receiving respite care. This area needs to be covered by a written policy so as to ensure there is minimum risk to resident’s who are admitted for respite care, but who subsequently reside on a permanent basis. There are no guidelines for medicines prescribed on a ‘when required’ basis, and a list of sample signatures for those members of staff administering medicines was not available. A number of recording errors were found on the Medicine Administration Record (MAR) charts. These included new medication being written on the MAR chart in the same space as another item, one resident had two identical MAR charts (both being signed at various times), a MAR chart not indicating the exact number of tablets being administered, a medicine given that was not being recorded on any MAR chart, a MAR chart that contained a dosage error and changes made to MAR charts which had not been verified and dated. The records for the auditing of medicines were examined. It was identified that on occasions medicines being received into the service are not being recorded, whilst the disposal records sheets are situated in a loose-leaf file and the sheets are not numbered. Disposal records for controlled drugs were seen to not always indicate the final balance to be ‘nil’. It is noted that the home has tried to source some training so that medicine management issues can be addressed but that this has yet to take place. The manager and deputy manager acknowledged that there were a number of errors in their system of medicine management and accepted that such poor practice is not ‘good enough’ and needs to improve without delay. Interactions seen between staff and residents indicated that residents are treated with respect, dignity and care. Many residents stated that they are treated ‘extremely well’ by staff and one resident noted that ‘they wouldn’t want to live anywhere else as you are looked after here’. Staff encouraged residents to engage in the daily routines of day, such as the lunchtime meal and morning activity, in an unhurried and patient manner with obvious care and understanding of the individual needs of each resident. One relative spoken with noted that the home had made their mother feel ‘much happier’ than her previous home. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 12 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from appropriate routines and opportunities are provided to allow them to pursue their individual and group interests and activities. The home encourage and support residents to maintain contact with their families/carers and friends. The dietary needs of residents are met. EVIDENCE: Residents can choose what time they would like to get up in the morning or retire to bed in the evening with times of meals being advertised around the home. Some residents choose to take their meals in their rooms, though most were seen to enjoy the lunchtime meal that was taken in the dining room in a pleasant atmosphere. The home have employed the services of an activities co-ordinator who visits the home twice a week, whilst a hairdresser visits fortnightly. A daily activities programme is displayed in the home on a weekly basis and include group games such as quizzes, skittles and exercise, whilst individual pursuits such as painting are supported when possible. The activities co-ordinator noted that care staff encourage resident participation in activities and felt that most events are ‘fairly well attended’. One resident commented that they Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 13 particularly enjoyed the interactive games such as throwing a bean bag at large letters on the floor and having to come up with a name starting with that particular letter, as this kept their ‘mind active and alive’. The home recently arranged for a singer to visit who sang songs from the 40’s and 50’s, whilst an exercise facilitator attends the home once a fortnight. One resident stated that they enjoy going for a walk with the activities coordinator, though noted that this cannot always take place as the ‘lady is often too busy doing group events’. Several residents commented that they are able to engage in their chosen religion either by attending their local church or by attending the services that take place at the home on a monthly basis. The home have a relaxed visitors policy and residents can have guests visit them at any reasonable time of the day. The visitors book confirmed that some residents receive regular visits from their families/carers and friends. Relatives stated that they feel they can visit the home ‘whenever they wished’ and noted that the home was ‘settled and happy’ when they arrived. The homes menu was viewed and this was seen to offer residents a varied, nutritious and appetising diet. The cook noted that she is able to meet any of the special dietary needs of residents and commented as to the success of now having alternative meals each day as this allows residents greater choice. The Inspector was invited to have lunch with the residents. The meal was found to be well prepared, home cooked and tasty. Most residents spoken with commented positively on the meals they receive and stated that the food was ‘very nice indeed’ and ‘the puddings are especially good’. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 14 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, 17 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home have a suitable written complaints procedure but must ensure that any concerns or complaints are addressed appropriately. Residents are supported to maintain their civil rights. Residents are protected from the risk of harm, neglect or abuse. EVIDENCE: The home has a suitable complaints procedure which clearly outlines it’s responsibility for addressing any concerns or complaints made about the home, it’s staff, or the service it offers. A copy of this policy and procedure was clearly displayed in a communal area of the home. The complaints book was viewed. This was found to contain an error whereby the most recent concern/complaint had not been recorded. There was evidence of the manager responding to the matter via a written letter to those concerned and also discussing and acknowledging the relevant issues with both of the Inspectors during the inspection visit. However by not recording the concern/compliant the home had not followed their complaint policies and procedures. The manager noted that she often takes any complaints, concerns or allegations ‘personally’ and acknowledged that this can occasionally lead to her initially responding to those expressing such issues in a defensive manner and Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 15 accepted that she is endeavouring to address future situations in a more objective fashion. The home have appropriate adult protection policies and procedures in place, including a policy on ‘whistle blowing’. Staff files indicated that adult protection issues are addressed in their induction programme and staff spoken to displayed a reasonable understanding of relevant adult protection concerns and procedures. All residents are registered with local GP’s and are supported in maintaining their civic rights such as being assisted to vote by post in the last election. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 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, 20, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is suitably maintained both inside and out and residents benefit from spacious, homely surroundings and personalised bedrooms. The health and safety of residents, staff and visitors must be adequately maintained to ensure that no one is at risk of injury or harm. EVIDENCE: A tour of the premises confirmed that Thornbury is furnished with domestic style fittings and carpets and is kept warm and airy, with a satisfactory level of natural and artificial light. A number of residents agreed to have their bedrooms viewed. These were found to be clean and well maintained and had been individualised by the resident with personal items such as photographs, pictures, and ornaments. One vacant room was being decorated at the time of the inspection visit and the maintenance person stated that every room gets redecorated prior to a new resident moving in. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 17 Thornbury was found to be well maintained both inside and out, with a satisfactory standard of decoration visible throughout the home. The home was found to be clean, tidy, and free from offensive odours or smells. The homes stairlift was tested and was found to be in good working order. Of concern were a number of resident’s bedroom doors that were found to have been propped open by wooden door-stops. A further issue identified during the tour of the building was a small top window in a resident’s bedroom, whereby the window hinge was found to be somewhat loose leading to the window opening to it’s fullest extension when the wind blew; this has subsequently lead to the resident attempting to close the window by climbing on to their bed. Records confirmed that on one previous occasion this led to the resident falling onto the floor after attempting to close it. The manager produced a letter from a window company confirming they are to fix the window within the next two weeks, however in the meantime a risk assessment should be completed to reduce any current risk to the resident. Fire records confirmed that regular fire alarm and emergency lighting checks had been completed, whilst the fire safety equipment had been recently serviced. Evidence of staff attending fire safety training was also seen. The accident record book was viewed and this evidenced a satisfactory standard of the reporting of incidents with clear descriptions on the nature of the incident and any outcomes that occurred as a result. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Thornbury deploy suitably experienced care staff to meet the assessed needs of residents, though staffing numbers during the night should be kept under review. The home must ensure that all legislation in respect of the recruitment of staff is adhered with so as to ensure residents are protected from the risk of harm at all times. EVIDENCE: The staff rota was viewed and this confirmed a satisfactory level of staff care cover during the daytime. The home continue to deploy a minimum of three members of care staff during the day, with an additional member of care staff on duty during the busy morning hours. In addition to this the manager or deputy manager are also available during office hours. During the night the home deploy one member of care staff to carryout ‘waking night’ duties with either the manager, who lives nearby, or her deputy facilitating an ‘on-call’ system as support. Staff cover during the night was discussed at some length with the manager and her deputy. The manager stated that it is planned that a staff sleep in room will be created within the next six months that will allow an additional member of care staff to be available on site during the night. Records indicate that many care staff employed at Thornbury have had previous experience in the care industry. The home has a suitable induction and training programme that addresses such areas as adult protection, safe Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 19 handling and lifting, health and safety, first aid, and medicine administration for which certification has been given. Records also indicated that all care staff training needs and requirements have now been recorded, with evidence of further training planed for each member of care staff. A number of care staff have either completed or are currently undertaking National Vocational Qualifications (NVQ) in care and it was clear that many staff are keen to continue to pursue their training to further awards. When those currently undertaking NVQ awards complete their training the home should meet the required level of 50 care staff with a minimum of NVQ level 2 in Care. The home have recently employed two new members of care staff. On viewing their staff records it became clear that neither of them had Criminal Records Bureau (CRB) or Protection of Vulnerable Adults (POVA) checks completed. The manager stated that there had been a ‘delay’ in receiving one CRB check back but accepted that she should not have allowed either member of staff to work without a minimum of a POVA check being completed. It is concerning to note that the previous report identified a similar failure to comply with recruitment procedures. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 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, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager conveys a wealth of relevant experience and knowledge and manages the home for the benefit of residents. EVIDENCE: The provider/manager of Thornbury has been providing a residential care service for older people at the home for 20 years and subsequently commands a vast understanding of the needs of residents. She is currently completing the National Vocational Qualification (NVQ) Level 4 award in Care and Management and expects to complete the course this year. Since the last inspection the management team have further developed the system of formal supervision for care staff and records indicated that a suitable Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 21 format is now being operated with all care staff receiving regular supervision. No regular staff meetings currently take place at the home. The home carried out a quality assurance survey in January this year by sending out questionnaires to relatives/carers and residents themselves, this was followed up by a residents survey in relation to the standard of catering in the home. The latter survey led to more alternative meal choices being added to daily menu. The home also have a visitors questionnaire that can be completed by anyone coming to Thornbury, the forms are located next to the visitors book in the entrance to the home. The home is not involved in managing any of the personal finances of residents. Records confirmed that in general the management approach in regard health and safety issues are suitably addressed, however as previously mentioned many resident’s doors were found to be wedged open by wooden door-stops thus creating a potential fire safety hazard to all those at the home. Records such as the fire log, hot water temperature checks and electrical maintenance files were found to be up to date and accurate. On viewing accident records and discussing recent events with the manager it became apparent that some accidents/events that have occurred in the home, such as a resident passing away in hospital and another being admitted to hospital following a fall, despite being recorded appropriately on site, were not reported to the CSCI as required by legislation. The manager acknowledged that she and her deputy must improve the system for informing the CSCI of reportable matters. Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 2 Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12(a) Requirement That pre-admission assessments must confirm the medication needs of residents and detail the manner that such medication is to be administered. That pre-admission assessments must confirm the medication needs of residents and detail the manner that such medication is to be administered. That pre-admission assessments must confirm the medication needs of residents and detail the manner that such medication is to be administered. The home must have written policies and procedures that cover every aspect of medicine management. The home must have clear guidelines for medicines prescribed on a ‘when required’ basis. The home must have an accurate record of the medication profile and history of administration for each service user. That any hand written changes DS0000021270.V287030.R01.S.doc Timescale for action 20/04/06 1 OP9 12(a) 20/04/06 1 OP3 12(a) 20/04/06 2 OP9 13(2) 31/07/06 3 OP9 13(2) 31/05/06 4 OP9 13(2) 31/05/06 5 OP9 13(2) 31/05/06 Page 24 Thornbury Version 5.1 6 7 OP9 OP9 13(2) 13(2) 8 8 9 9 10 OP37 OP16 OP37 OP19 OP37 22(3) 22(3) 23(4)(a) 23(4)(a) 12(1)(a) 10 OP19 12(1)(a) 11 OP29 19(4)(b) (iii) 12 OP38 37(1) (a) & (c) made to MAR charts must be verified (signed) and dated. The home must adopt a robust system for recording the disposals of medicine. The home must ensure that suitable training concerning medicine management is made available and that staff are competence skills assessed before they are delegated the task of medicine administration. That all complaints, concerns or allegations received by the home must be recorded appropriately. That all complaints, concerns or allegations received by the home must be recorded appropriately. That fire resistant doors must not be held open by door stops. That fire resistant doors must not be held open by door stops. That the home must complete a risk assessment for the resident who has been known to place themselves at risk when they open or close their bedroom window. That the home must complete a risk assessment for the resident who has been known to place themselves at risk when they open or close their bedroom window. The home must not allow staff to work at the home prior to gaining confirmation of the required CRB/POVA checks (outstanding from the previous inspection). The management team must inform the CSCI of any matter as described in Regulation 37 as and when it occurs. 31/05/06 31/05/06 20/04/06 20/04/06 20/04/06 20/04/06 20/04/06 20/04/06 20/04/06 20/04/06 Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 25 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 OP1 Good Practice Recommendations The home should clarify the definition of ‘respite care’ notably in respect of the maximum length of time considered to be ‘respite’ and should amend it’s statement of purpose accordingly. The home should identify a suitably trained/competent member of care staff to hold responsibility for medicine storage and administration on every shift and should clearly identify them on the daily rota. The home need to ensure that information is entered correctly into the controlled drugs register. The home should implement a checking/auditing procedure to improve the accuracy of hand-written MAR charts by a second member of staff before the administration of that medication. That the home should facilitate a move toward adding an additional member of care staff on site, as a ‘sleep-in carer’, during the night. That the home should consider introducing a programme of regular staff meetings. 2 OP9 3 4 OP9 OP9 5 6 OP27 OP36 Thornbury DS0000021270.V287030.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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