Inspection on 12/11/05 for Thorncliffe Grange Nursing Home

This inspection was carried out on 12th 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

Thorncliffe Grange Nursing Home 23/09/08

Thorncliffe Grange Nursing Home 04/10/07

Thorncliffe Grange Nursing Home 17/05/06

Thorncliffe Grange Nursing Home 25/04/05

Thorncliffe Grange Nursing Home 25/11/04

Thorncliffe Grange Nursing Home 19/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Thorncliffe Grange Nursing Home 2-4 Windmill Lane Denton Tameside M34 3RN Lead Inspector Mrs Fiona Bryan Unannounced Inspection 12th November 2005 09:30 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 Thorncliffe Grange Nursing Home DS0000043576.V263245.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. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thorncliffe Grange Nursing Home Address 2-4 Windmill Lane Denton Tameside M34 3RN 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) 0161 320 0740 0161 320 7374 Partnership Caring Limited Care Home 50 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (50), of places Physical disability (50), Physical disability over 65 years of age (50), Terminally ill (2) Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. For 26 - 50 service users requiring nursing care 2 Registered Nurses to be on duty over each 24 hour period. The Manager must be supernumerary at all times. No service user to be admitted into the home who is under 55 years of age. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. For up to 25 service users requiring nursing care 1 Registered Nurse to be on duty over each 24 hour period. The home is registered for a maximum of 50 service users to include up to 15 DE(E), up to 50 OP, up to 50 PD, up to 50 PD(E) and up to 2 TI. 25th April 2005 5. 6. Date of last inspection Brief Description of the Service: Thorncliffe Grange provides accommodation for up to 50 service users requiring personal and nursing care. The home is owned by a partnership and is under the control of a manager who is also a qualified nurse. The accommodation is within two converted Edwardian houses that are connected by a purpose built extension and link. The home retains many of the original features of both properties. Accommodation is provided over two floors. 21 of the bedrooms are single en-suite whilst a further 18 single rooms, without en-suite facilities, are provided with washbasins. Five rooms are double rooms, two being en-suite and three not. A large lounge with attached conservatory is provided on the ground floor with a small dining room also available. On the first floor service users can utilise a large lounge/dining room. The home is located off the main A57 in the town of Denton. It is on the main bus route and is close to Denton town centre. It is also close to the M60 and M57 motorways. There is ample parking for those who choose to travel to the home by car. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Saturday 12th November 2005 and was the second inspection for the year. At the last inspection on 25th April 2005 immediate requirements were made in respect of staffing levels, care planning and risk assessments, medicine storage procedures and visits made by the owner. A monitoring visit was carried out on 9th June 2005 when further immediate requirements were issued in respect of staffing levels and visits to the home by the owner. The timescales for the home to address the issues regarding care planning and risk assessments had been extended to June 2005 and were being worked on at the time of the monitoring visit. A further monitoring visit took place on 12th July 2005. As many of the standards were not met at the last inspection they were reviewed again at this inspection to assess if any improvements had been made. Since the inspection in April 2005 the CSCI has received one telephone call from a relative expressing concern about the standards of care, staffing levels and competence of staff at the home. Whilst this was not dealt with as an official complaint the issues raised were looked at during the monitoring visit on 9/7/05 and many were found to be valid. The CSCI has also received two telephone calls from staff with concerns about staffing levels and one telephone call from a health care professional who visits the home and raised concerns about care practices. Other information was obtained from a questionnaire completed by the manager prior to the inspection. During the visit the inspector spent time talking to residents, relatives and staff. Four residents were looked at in detail, looking at their experience of the home from their admission to the present day. A selection of documents were examined including residents’ care files and medicine records, staff duty rotas and training records. As this visit took place on a Saturday the manager was not on duty and a further visit was made to the home on Monday 28th November 2005 to complete the inspection and give feedback. What the service does well: Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 6 Although the provision of meals was not formally assessed at this inspection as it had been found to be satisfactory at the last inspection, it was noted that a very appetising meal of home made minced beef and onion pie was served for lunch, which was very much enjoyed by the residents. Residents were also able to order a cooked breakfast if they wished and home made cakes and scones were provided between meals. At tea time residents had a choice of sandwiches or a hot meal of cheese, onion and potato bake. Visitors are made welcome and several visitors have regular meals with their relatives at no extra cost. What has improved since the last inspection? What they could do better: Although assessments are undertaken of residents before they are admitted to the home, on many occasions information was missing which means that there is a risk that some of the residents care needs may not be identified. Slight progress has been made in respect of care planning but care plans still do not always reflect the needs of all the residents and are not reviewed often enough to make sure that changes to residents’ needs are quickly identified and acted upon. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 7 Staff must follow medicine storage and administration procedures carefully to ensure that risks to residents are reduced. There were not enough staff on duty to provide a high standard of care and the poor staffing levels were reflected in the lack of activity and physical and mental stimulation for residents. In addition there were shortfalls in the numbers of cleaning staff so some areas of the home were untidy and not very clean. Medical equipment was also not cleaned properly and the staff must review their practices in respect of infection control. The owner must visit the home monthly or delegate someone to do this on his behalf so he can make sure that residents are being cared for properly and improvements are continuously made and a report must be supplied to the CSCI. On the day of the inspection as the manager was not on duty, a feedback form was left at the home requiring a light bulb in the stair well to be replaced, a risk assessment to be undertaken for one resident who was putting other residents at risk and to ensure there were enough staff on duty at all times to meet the needs of the residents. These issues needed to be addressed before the inspector returned to the home on 29th November 2005 and were reviewed at that time. The first two items had been dealt with but staffing remains an ongoing problem. 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. Thorncliffe Grange Nursing Home DS0000043576.V263245.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 Thorncliffe Grange Nursing Home DS0000043576.V263245.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 and 4 The pre admission assessment process requires more rigour to ensure that all the personal, social and health care needs of residents are identified so that the residents can be assured their needs can be met. EVIDENCE: One resident who had come into the home the previous week confirmed that the manager had been to see her in hospital and she had been able to give her opinions about what her care needs were. Four residents’ care files were examined in detail. Pre- admission assessments had been undertaken before the residents were admitted to the home. However, the pre-admission details for one resident who had recently been admitted to the home differed from the information that was written on the admission documents, for example stating that the resident could walk short distances on one document and stating that the resident had to be moved by hoist on the other document. The information on the admission document was also very limited, relying mainly on tick boxes with no additional detail. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 10 Information about residents’ social history, and background detail regarding previous occupations, hobbies, interests and family contacts were sparse. Thorncliffe Grange Nursing Home DS0000043576.V263245.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 and 10 Care plans do not fully identify the needs of the residents, which leads to the risk that their needs will not be met. More consideration is needed as to how residents’ health care needs are monitored. Failure to follow the correct procedures in the storage and administration of medicines puts residents at risk. Residents felt they were treated with respect. EVIDENCE: Four residents’ care files were looked at in detail. Care plans did not always give enough information to be able to care for residents properly. Some important care needs were not addressed adequately, for example with the care plan for one resident with diabetes containing no details about how their condition would be monitored. Some care needs were not addressed at all, for example one resident who was presenting management difficulties due to aggression did not have a care plan in place in relation to this. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 12 Care plans for one resident had not been dated and no evidence was available that they had been reviewed. Care plans for other residents had also not been reviewed monthly. Actions stated in care plans were not always carried out, for example one resident was identified as being at risk of falling and her care plan advised staff to ensure her footwear was safe but she was observed trying to walk in very poorly fitting slippers. Risk assessments had not been undertaken for some residents where they were clearly indicated. Where risk assessments had been written they failed to identify suitable interventions to reduce the risk. More consideration needs to be given as to how residents’ health care needs are monitored as one resident who was bed bound had not been weighed but still required assessment and evaluation of nutritional needs. One health care professional who returned a comments card felt that the nurses’ knowledge of wound care was minimal. One care plan had no detail about the type of pressure relieving mattress that was needed and no risk assessment for pressure sores although the resident actually had a pressure ulcer. Records showed that residents had been seen by GP’s, DN’s, chiropodists and had attended hospital outpatient appointments. Examination of a small selection of residents’ medicine administration records indicated that medicines had been signed for accurately and contemporaneously. Specimen signatures were available for all staff with responsibility for administering medicines. Some medication administration details were handwritten. These transcribed details had not been signed, dated or validated by an additional member of staff. Topical preparations were observed in one resident’s bedroom. These should be kept in a lockable storage space. Oxygen cylinders were stored in the treatment room without adequate safety signage. The oxygen was not prescribed for a specific resident but was kept “as stock”. Oxygen must not be administered to residents unless prescribed by their GP. An excessive amount of medication stock was noted especially in liquid medicines for some residents. Stock should be regularly rotated and reviewed each month before re-ordering to ensure that stock levels are appropriate. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 13 One new resident said staff had been very kind to her and had helped her to settle quickly into the home. Staff were observed to treat the residents with courtesy and kindness. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 14 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 The home does not satisfy residents’ social and recreational needs. EVIDENCE: Residents and staff reported that a firework display and potato pie supper for residents and their relatives had taken place to celebrate Bonfire Night. With the exception of this residents said that activities within the home were minimal. Two different notices in the reception area provided conflicting information about activities. The manager acknowledged that in reality these activities did not take place and the low staffing levels, which affect the domestic staff as well as the care staff reduces the likelihood that a meaningful programme of activities will be arranged for residents. Thorncliffe Grange Nursing Home DS0000043576.V263245.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 and 18 Complaints were managed satisfactorily. The lack of adequate risk management places residents at risk of abuse. EVIDENCE: The home’s complaints procedure was displayed in the reception area. Included in this were the anticipated timescales by which complainants could expect a response, and contact details for the CSCI. A record of complaints received by the home had been maintained which included details regarding any investigation that took place and any action taken. Seven complaints had been recorded. Some staff had received training in the prevention of abuse and were aware of procedures to follow. One resident had been upset by another resident coming into her room and behaving in an intimidating way. The resident remained unhappy and insecure, as she was not aware if any action had been taken to safeguard her against further incidents. No risk assessment had been developed to advise staff about how to minimise the risk of future incidents. A requirement was made for this situation to be reviewed and a risk strategy to be implemented. At the subsequent visit on 28th November 2005 it was reported that this had been undertaken. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 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, 21, 24, 25 and 26 Improvements were noted in some of the communal areas and residents’ rooms, but further improvement must continue. Bathing facilities did not meet all the residents’ requirements. Shortfalls in hygiene procedures put residents at risk of infection. EVIDENCE: A number of rooms on the ground floor had been redecorated and new bedding and carpets had been provided. The manager said residents had been able to choose their own colour schemes. At the last inspection a requirement was made that bedrooms were redecorated at the rate of four per month and this requirement will remain in force until all bedrooms have been upgraded. The hallways on the ground floor had been redecorated and looked much brighter and cleaner and the entrance hall appeared bright and welcoming. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 17 At the time of the inspection alterations were being made to the manager’s office so that the administrator could also work downstairs and be more accessible to residents and relatives. A bathroom on the ground floor was being converted to a disabled shower room. The timescale for a requirement made at the last inspection regarding bathing facilities has been extended to allow time for this work to be completed. The main lounge on the ground floor had been redecorated and the conservatory area was in the process of being redecorated. The lounge looked much brighter and the furniture had been rearranged to create a more homely feel. New occasional tables had been purchased and a stereo system had been donated by a relative. A DVD player had been purchased for the first floor lounge. A smaller lounge on the ground floor, which was not often used had been redecorated and is now being used as a dining room. The dining tables were attractively laid with table cloths and napkins and residents said they enjoyed eating their meals in a separate room as it made mealtimes more of an “occasion”. Small maintenance jobs had not been carried out as the home did not have a maintenance person. A light on the main landing was not working, causing the stairs to be lit only by emergency lighting. A requirement was made to ensure that adequate lighting was provided for the hallway and this was complied with at the time of the inspector’s second visit on 28th November 2005. At this visit it was also reported that a maintenance person had been appointed. One resident was confined to bed and the room was not very homely or appealing, being badly in need of redecoration and untidy with notices to staff on the walls, and several half used bars of soap around the sink area. Much of the bedroom furniture was shabby and old. On the return visit to the home for feedback it was noted that some of this furniture had been replaced with other second hand furniture, which was of slightly better quality. Two residents who required enteral feeding had feeding pumps in their rooms, which had not been cleaned properly and had splashes of old feed on them. Many of the windows, especially in residents’ rooms were dirty. At the time of the inspection there were no cleaners on duty and it was reported that there were no cleaners scheduled for the whole weekend. Some toilets were dirty and bathroom areas contained communal toiletries and unwashed urinals. Inadequate cleaning regimes and poor hygiene practices in respect of residents’ equipment puts them at risk of infection. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 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 and 30 Insufficient numbers of staff are provided to meet the needs of the residents. The percentage of care staff working at the home who have completed NVQ training does not meet the required targets. Staff training has improved since the last inspection but further training is required to ensure that all staff have the skills and knowledge to deliver care to the residents competently. EVIDENCE: At the time of the inspection there were insufficient staff to meet the residents’ needs. Examination of staff duty rotas indicated that there were often only three staff on duty (including the nurse) to care for 23 residents on the first floor. In addition to this there were shortages in the number of cleaning staff and there was no maintenance person. One of the carers was observed vacuuming the carpet at lunchtime. If care staff are having to also carry out domestic duties because of the shortage this has an additional impact on their ability to meet the residents’ care needs. Two residents and one relative stated that the home was often short staffed. It was also reported that when residents used the nurse call system to call for assistance it often took the staff a long time to respond. Where it is known in advance that extra staff will be required for a shift and the home’s own staff are not able to cover it, every effort must be made to Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 19 obtain the services of temporary staff/agency staff to ensure that sufficient staff are on duty to meet the needs of the residents. At the return visit for feedback it was reported that a new maintenance person had been appointed. Six care staff have successfully completed NVQ training. However this figure does not meet the target of 50 of care staff in the home having this qualification by the end of 2005. Staff said they had received training in catheterisation, waste management and mental health awareness, in addition to mandatory health and safety training. A training file confirmed that staff had attended a variety of training courses. Consideration should be given to the home’s system for accessing and paying for training as it seemed that by the time funding had been agreed by the owner the available places had often been reserved by staff from other homes. Thorncliffe Grange Nursing Home DS0000043576.V263245.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): 33 and 38 Residents are not consulted on how the home is run. Staff practices do not protect the health, safety and welfare of residents. EVIDENCE: The manager will be starting the registered managers award in May 2006 and is in the process of applying for registration with the CSCI. The CSCI has not received notification of Regulation 26 visits since July 2005, although the manager stated that the registered provider regularly comes into the home. The type of information to be forwarded to the CSCI was discussed with the manager. Since the last inspection a freezer has been replaced in the kitchen and a number of requirements that were made as a result of an inspection from the fire service were being carried out. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 21 Staff have received training in fire safety and nine staff have received first aid training. As previously stated in this report, bathrooms contained communal toiletries. Areas of the home and residents’ equipment were inadequately cleaned. Poor hygiene practices put residents and staff at risk of infection. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 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 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 X X 2 2 2 STAFFING Standard No Score 27 1 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X X X 2 Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3OP4 Regulation 14 Requirement Timescale for action 24/12/05 2. OP7 15 3. OP7 13 The registered person must ensure that an assessment of all residents is completed prior to admission to the home, which includes all the details listed in Standard 3. (Timescale of 31/5/05 not met). The registered person must 31/01/06 ensure that residents care plans set out in detail the action which needs to be taken to ensure that all aspects of the health, personal and social care needs of the residents are met and must ensure that the stated actions are carried out. (Timescales of 31/1/05 and 30/6/05 not met). The registered person must 15/01/06 ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. (Timescales of 10/5/05 and 30/6/05 not met). Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 24 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. 4. Standard OP7 Regulation 15 Requirement The registered person must ensure that care plans and risk assessments are reviewed at least once a month or more often if necessary and updated to reflect the changing needs of the residents. The registered person must ensure that a record is maintained of the incidence of pressure sores and the treatment provided. The registered person must ensure that warning notices prohibiting smoking and naked lights are posted clearly on the entrances to any room in which oxygen is stored or in use. Oxygen must not be kept for emergency use unless prescribed by a medical practitioner. The registered person must ensure that handwritten medication details on the medicines administration records are signed and dated, and the details are validated by an additional member of staff. The registered person must ensure that topical preparations that are kept in residents’ rooms are stored securely. Timescale for action 15/01/06 5 OP8 17 15/01/06 6. OP9 13 31/01/06 7. OP9 13, 17 15/01/06 8 OP9 13 24/12/05 Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 25 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. 9 Standard OP9 Regulation 13 Requirement The registered person must ensure that stocks of medicines are rotated regularly and that stock is checked each month prior to medicine ordering to prevent the build up and wastage of excess medicines and supplies. The registered person must ensure that residents are consulted about their interests, and make arrangements to enable them to engage in local, social and community activities and provide facilities for recreation. (Timescale of 15/6/05 not met). The registered person must ensure that a risk assessment and associated risk management plan is completed in respect of the resident identified during the inspection. The registered person must ensure that a minimum of four bedrooms per month are redecorated and refurbished. The registered person must ensure that the ratio of usable assisted baths provided to residents remains the same as was provided at 31st March 2002 (Timescale of 30/6/05 not met). Timescale for action 24/12/05 10 OP12 16 30/01/06 11. OP18 13 24/11/05 12. OP19 23 31/03/06 13. OP21 23(2) 15/01/06 Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 26 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. 14. 15 16 Standard OP24 OP25 OP25 Regulation 16(2) 23 23 Requirement The registered person must ensure that old and worn bed linen and towels are replaced. The registered person must ensure that all windows in the home are cleaned. The registered person must ensure that adequate lighting is provided in the stairwell identified during the inspection. The registered person must ensure that the programme of cleaning within the home ensures that the environment and equipment are hygienic and reduces the risk of infection. (Timescale of 31/5/05 not met). The registered person must ensure that at all times suitably qualified, competent and experienced staff are working at the home in such numbers as are appropriate for the health and safety of the residents. (Timescales of 31/1/05 and 10/5/05 not met). The registered person must ensure that staff receive training appropriate to the work they are to perform. Timescale for action 31/03/06 15/01/06 23/11/05 17. OP26OP38 16 15/01/06 18. OP27 18(1) 31/01/06 19. OP30 18 31/03/06 Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 27 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. 20 Standard OP33 Regulation 26 Requirement The registered person must ensure that monthly visits are undertaken in accordance with regulation 26 of the Care Homes Regulations 2001, and a report about the visit is supplied to the CSCI. (Timescales of 31/1/05 and 10/5/05 not met). Timescale for action 24/12/05 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 3 4 Refer to Standard OP8 OP28 OP30 OP38 Good Practice Recommendations The registered person should ensure that other methods of monitoring residents’ health care needs are explored if it is not possible to use standard assessment tools. The registered person should continue to recruit permanent care staff with NVQ’s or train existing staff to ensure that the target ratio is achieved. The registered person should review the existing system used by staff to apply for and access funding for training courses. The registered person should ensure that residents have their own toiletries and they are kept in their own rooms. Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Thorncliffe Grange Nursing Home DS0000043576.V263245.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!