Inspection on 12/05/06 for Thornton Manor Care Home

This inspection was carried out on 12th May 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

Thornton Manor Care Home 05/02/09

Thornton Manor Care Home 30/12/08

Thornton Manor Care Home 15/12/08

Thornton Manor Care Home 26/06/08

Thornton Manor Care Home 11/07/07

Thornton Manor Care Home 07/12/06

Thornton Manor Care Home 03/11/05

Thornton Manor Care Home 17/05/05

Thornton Manor Care Home 15/09/04

Thornton Manor Care Home 27/04/04

Thornton Manor Care Home 15/12/03

Thornton Manor Care Home 24/06/03

Thornton Manor Care Home 21/11/02

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

CARE HOMES FOR OLDER PEOPLE Thornton Manor Care Home Thornton Green Lane Thornton Le Moors Cheshire CH2 4JQ Lead Inspector Wendy Smith Key Unannounced Inspection 12th May 2006 9 am 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 Thornton Manor Care Home DS0000018787.V289516.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. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thornton Manor Care Home Address Thornton Green Lane Thornton Le Moors Cheshire CH2 4JQ 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) 01244 301762 01244 301985 Mr Barry Potton Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (11) of places Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Inspection Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection The service is registered to accommodate a maximum of 47 service users in the category OP (Old age, not falling within any other category) Within the maximum number of service users to be accommodated, no more than 11 people under the age of 65 years may be accommodated within the category PD (Physical disability) until 25th July 2005 3rd November 2005 Date of last inspection Brief Description of the Service: Thornton Manor is a three storey building that has been extended and adapted as a care home for older people and younger adults with a physical disability. The home is set in its own grounds in a rural location between Ellesmere Port and Chester. It is close to the motorway network but is not accessible by public transport. There is parking space to the front of the building and gardens to the front, side and rear. Bedrooms are on the ground and first floors, with a passenger lift and staircases providing access to the first floor. All bedrooms have a hand washbasin and 21 rooms have an en-suite toilet. The third floor is used as office space. On the ground floor there is a main lounge, a dining room, a games room and a smoking lounge. There is a lounge/dining room on the first floor. There are assisted bathrooms on both floors and a call bell system is available in all rooms. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two regulatory inspectors and a pharmacist inspector. The home had 42 residents, of whom twelve were under 65 years of age. Time was spent in conversation with the manager and with the proprietor. A number of staff were also spoken with. A number of residents and visitors were spoken with and in general they were satisfied with the care they were receiving. A sample of care plans was looked at and medicines were inspected by the pharmacist. Management records were looked at. Comments cards were sent to GP’s and social workers, and comments cards were also left at the home for relatives/visitors to complete. The home’s fees are from £329 to £500 per week. What the service does well: What has improved since the last inspection? The home manager has been in post for seven months and she has made significant improvements to the overall standard of record keeping. She is in the process of updating the home’s policies and procedures. The standard of the care plan documentation has improved considerably since the last inspection. Care plans are presented in a more orderly form and provide more details of each resident. The management of medicines has improved. There was evidence of greater attention to the social and recreational needs of residents. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 6 The standard of décor and cleaning throughout the home has continued to improve. There was evidence that the quality of the service is being monitored to ensure that the needs of residents are met. What they could do better: Complete the application process for the manager to be registered with the Commission for Social Care Inspection. Ensure that all residents admitted to the home are frail older people or adults with a physical disability and that no more than eleven people under the age of 65 years are accommodated. Ensure that all possible safeguards are put in place to protect residents and staff from the risk of fire. Make sure that all medicines are recorded properly and are given according to prescribed directions. Make arrangements to ensure that all medicines, including controlled drugs, are stored properly. Ensure that all documents in the care plans are completed in full and that there is a photograph of the resident. Protect the privacy and dignity of residents by ensuring that any treatment is provided in the resident’s bedroom and that catheter bags are worn discreetly. Update the home’s adult protection policies and procedures and continue with the training for all staff. Recruitment records must be available in the home to demonstrate that good recruitment practices have been followed for the protection of residents. Complete the training matrix to show what training each member of staff has received and on what date. Maintain accurate records of money in safekeeping for residents and review the arrangements for making purchases on behalf of residents. Keep the cellar door locked. Display the home’s current certificate of registration with the Commission for Social Care Inspection. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 7 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. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 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 Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered numbers and categories of registration are not adhered to and this has been explained to the proprietor and the manager. Standard 6 is not applicable. EVIDENCE: The manager has a developed a ‘patient diary’ matrix that shows details of all residents living at the home including name, room number and resident category. Inspection of the ‘patient diary’ showed that twelve residents are under 65 years of age. The registration of the home is for a maximum of eleven residents under 65 years. A sample of care plans looked at showed that recently admitted residents had been assessed by a social worker and by the home manager prior to admission. Copies of the assessment documents were contained in the care plans. Thornton Manor is registered to provide care for people in two Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 10 registration categories which are older people (not falling within any other category) and adults with a physical disability. One recently admitted resident had an enduring mental illness but had no apparent physical disability, and another had needs relating to past alcohol abuse. The home is not registered to accommodate residents in these categories. Since this visit, one of these people has been able to return home. Requirement made. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of care plans was much improved and provided evidence that the health needs of residents were met. The privacy and dignity of residents are not always upheld. Although a number of problems were found that needed to be addressed there was evidence that medicine management had improved since the last visit. EVIDENCE: Each resident has a care plan that sets out their assessed needs and how these needs are to be met. A sample of four care plans was looked at. The care plans were well organised and easy to follow and this is a great improvement from previous inspections. Not all documents were fully completed, for example resident detail sheets, death and dying arrangements, and agreement forms were not all signed. Some did not have a photograph. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 12 Daily record sheets in the care plans provided good information that the health needs of residents were met, including visits from GP’s and other health professionals. One resident required care for a pressure sore and this was fully documented. The home employs a physiotherapist on a part-time basis and there was evidence that the physiotherapist is involved in the assessment of residents and in providing exercises and other treatment. A comments card received from a health and social care professional stated that: Staff appear genuinely interested in what is advised and recommended and keen to learn. A nicer atmosphere in the home, more approachable. During the visit a nurse was observed changing a soiled dressing on a resident’s leg in the lounge. A female resident in the first floor lounge had a catheter bag dangling around her ankle. Requirement and recommendation made. A CSCI pharmacist inspected the medicines because of concerns raised by the lead inspector and continued non-compliance with an immediate requirement to manage medicines to the required standard. Policies and Procedures The home has its own medicine management policies and procedures. Records Many records of the audit trail of medicines were completed to a good standard but others were not so good. There were twelve omitted records of receipt but no unexplained gaps in the records. When doses of medicine are omitted staff have recorded the open omit code “F”. The form has a place to record the reason but this had not been completed. However the medicines omitted were mainly painkillers and laxatives that were not needed and would be better prescribed to be given only when required. Three service users’ records had hand written amendments that had not been signed by the person making the record. One of these was a dose alteration that was not clear. The home has a clinical waste contract for safe disposal of medicines. The records kept of medicine disposal do not clearly record the process. Administration On the whole medicines were administered satisfactorily but there were still some examples of poor practice. One service user was prescribed one painkiller but on three occasions two tablets have been recorded given. There was no evidence that medical advice had been sought to be sure that it was safe to increase the dose. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 13 Another service user was recorded to have had thirty doses from a twentyeight day supply of antibiotic tablets and another sixteen doses from a ten dose supply of antibiotic liquid. This would indicate that the courses have not been given and recorded properly. A separate audit sheet is kept for one service user’s painkiller. There was a discrepancy of two tablets that was accounted for by a missed entry on the 4th May 2006. Storage There is a designated medicine room that was clean and tidy. Each service user has a basket for those medicines backing up trolley supplies. These were well organised and there was no evidence of overstocking. One service user had some blister packed tablets in the basket, removed from its labelled container. There were also some loose paracetamol and steripod saline in the trolley. The trolleys were very full, the blister packs squeezed tightly into the shelves. Some of the trolley shelves were very sticky and the medicine containers were stuck to the shelves. There is a separate refrigerator for medicine storage. Its temperature was appropriate and recorded regularly. The refrigerator was very full, mainly due to a large amount of enemas that do not require refrigeration. A service user’s cream, labelled to store below fifteen degrees centigrade had not been refrigerated. There were two containers of eye drops, one that had lost its dispensing label and another that the label was so damaged it could not be read. Another bottle of eye drops in use in the refrigerator was marked with a date of opening as “27/2”, more than the recommended twenty-eight day shelf life stated by the makers. These eye drops are no longer guaranteed safe to use. Controlled drugs There is a cupboard available for the storage of controlled drugs. Some of the drugs available must be in it by law and others are recommended to be included but it is not a strict legal requirement. The bulky monitored dose packs of tablets, bottles of liquid and skin patches would not all fit into the cupboard so some were left outside the cupboard. Some of those left outside were those needing controlled storage by law and the ones in the cupboard those not strictly needing such storage. Additionally there was a pack of skin patches that was labelled to contain five patches that actually contained nine. It seemed that staff had compounded two boxes. There were some controlled drugs prescribed for a service user that passed away in March 2006 that need not have been kept so long. If staff had sorted out the cupboard there would have been no need to store these medicines illegally. Requirements made. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 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, 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. The home is making great efforts to meet the social needs of residents and they can receive visitors at any reasonable time. The standard of catering is good but dining space is limited. EVIDENCE: The chef said that he enjoys assisting some residents with cooking in the residents’ kitchen. Residents had been involved in the planting of seeds in trays in the conservatory. One resident had done some art work. There is a computer for residents to use. The home has not been able to recruit an activities organiser but one of the nurses has expressed an interest in getting involved in activities and a poster in the entrance area asked for donations of items for activities and assistance from visitors. The home has a minibus for taking residents out and a group of residents spoken with had enjoyed a recent trip out. The manager described plans for a new garden and to have Shetland ponies in an adjoining field. A resident said that he was not aware of any activities in the home except for one hymn Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 15 singing session that he had enjoyed, however the manager was able to provide evidence that activities do take place on a daily basis. Visitors are welcomed at the home at any reasonable time and there were several visitors during the inspection, including one lady who had taken her husband (a resident) out shopping. The manager provided information that five residents are able to look after their own financial affairs. All residents have a single bedroom and have their own personal items in their rooms. The lounge/dining room on the first floor appeared very crowded and a considerable number of residents were seated in wheelchairs in the afternoon although there was no apparent reason why they couldn’t be transferred to an armchair. The ground floor dining room has limited space for wheelchair users. Residents spoken with were satisfied with their meals. The menu for the day was written on a white board in the dining room and showed that choices were available. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place and complaints are recorded and acted on. Further work is needed to ensure that residents are protected from abuse. EVIDENCE: The manager has reviewed and updated the home’s complaints procedure. There has been one complaint recorded since new manager took up post and this was acted upon. Pre-printed complaints forms are available to record any complaints received. The home has policies and procedures for the protection of vulnerable adults however the manager has identified that these need to be updated. There is a copy of ‘No Secrets’ in the manager’s office. The manager is providing training for staff about adult protection and said that this had now been given to approximately one third of staff. Requirement made. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 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): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall standard of maintenance and cleaning is satisfactory and continues to improve. EVIDENCE: The manager provided information that 17 bedrooms and the ground floor corridors have been redecorated since October 2005. The manager said that a new carpet had been ordered for ground floor corridors. Some of the outside woodwork needs painting and a flat roof needs clearing of moss. Recommendation made. On the day of the inspection there were no unpleasant odours however survey forms completed by two relatives said that there was an unpleasant odour at the weekends and one said that staff are ‘always spraying’. Toilet 29 had not been cleaned properly and was badly soiled on the outside of the bowl. Thornton Manor Care Home DS0000018787.V289516.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. The home is fully staffed to meet the needs of residents and more than 50 of care staff have an NVQ or higher qualification. EVIDENCE: The home employs eight nurses, 21 care staff and ten ancillary staff. Eight carers have achieved an NVQ qualification, five are working towards it, and five overseas nurses are employed as carers. There has been no recent use of agency workers. On the day of the inspection there were two nurses on duty, six carers, two cleaners, a laundry assistant and catering staff. Staff spoken with were friendly and helpful. One carer said that she starts work at 7 am and this has helped to improve communication between day and night staff. Staff records relating to the four most recently recruited staff were looked at. The file for the first of these, a nurse, could not be found. The file for the second, also a nurse, contained an application form, medical declaration, Criminal Records Bureau disclosure, two good references (one from the last employer) and check of nursing registration. The file for the third, a carer, contained supervision record, Criminal Records Bureau disclosure, one reference, no application form or medical declaration. The fourth contained evidence that this person is an overseas registered nurse. The file also contained two references and a police clearance from her country of origin. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 19 Information provided by the manager showed that during last the 12 months members of staff have received training in the protection of vulnerable adults, food hygiene, skills for life, risk assessment health and safety, challenging behaviour, catheter care, and fire safety. Record keeping had improved but did not yet provide a full record of what training each member of staff had received and when. Requirements made. Thornton Manor Care Home DS0000018787.V289516.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 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a qualified and experienced manager who is not yet registered with the Commission for Social Care Inspection as manager of this service. Quality assurance systems are being developed. Residents are at risk due to health and safety issues. EVIDENCE: The manager is a registered nurse and has previous management experience. She is working towards the Registered Manager Award and expects to complete this before the end of 2006. A comments card received from a visiting professional described the manager as more approachable than previous managers. A district nurse spoken with said that she found the home more welcoming and that communication had improved. The manager has now Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 21 been in post for seven months and her manager application needs to be resubmitted to the Commission for Social Care Inspection without delay. Requirement made. There was evidence of meetings taking place for residents and relatives; the last was in February 2006. Monthly visits required by regulation 26 of the Care Homes Regulations are carried out by the proprietor. Care plan auditing is taking place. The manager is carrying out a satisfaction survey and showed the inspectors forms that have been returned so far. Staff spoken with were open and willing to talk with the inspectors. They considered that team spirit in the home was very good. The manager is in the process of reviewing all of the home’s policies and procedures. A system is in place for recording personal money in safekeeping for residents. Only small amounts of money were kept and were in individual envelopes. There were some small discrepancies in the recording. The manager buys toiletries for residents with her own money and is later reimbursed. It would be good practice for petty cash to be used for such purposes. Recommendation made. A health and safety meeting was held in January 2006 and a number of issues were raised for example fire doors left open, fire escape blocked, footplates missing from wheelchairs. A second meeting was held in March. The minutes show issues raised, but no plan of action to address them. Moving and handling training for staff is provided by a physiotherapist who is employed part-time in the home. The cellar door was not locked which meant that residents could have access to steep concrete steps. The door of bedroom 9 was wedged open. A resident smokes in his bedroom on the first floor. The manager said that he has been offered a room on the ground floor, close to an exit, but refused. The bedroom door was wide open allowing smoke to affect other parts of the home, and presenting a fire risk to other residents, staff and visitors. The manager provided evidence of regular testing and servicing of plant and equipment. Some of the records were checked during the visit and were up to date. A fire officer visited the home on 2nd May 2006 but, at the time of writing this report, the fire officer’s report was not yet available for the inspector to look at. Weekly fire alarm tests and monthly emergency lighting tests were recorded. There was a record of fire drills, including names of staff attending, however a full list of fire safety training was not available. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 22 Requirements made. An old National Care Standards Commission registration certificate was displayed. The current registration certificate was issued to the provider on 8th June 2005 and this should be displayed. Requirement made. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 1 Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 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 OP3 Regulation Care Standards Act 2000 PII 13(3) 13 Timescale for action The registered person must 12/05/06 ensure the home’s conditions of registration are met at all times. The registered person must make arrangements to ensure staff make all records of medicines properly. The registered person must make arrangements to ensure that all medicines are given according to prescribed directions. The registered person must make arrangements to ensure that all medicines are stored properly. The registered person must make arrangements for controlled drugs to be stored legally at all times. 12/05/06 Requirement 2 OP9 3 OP9 13 12/05/06 4 OP9 13 12/05/06 5 OP9 13 12/05/06 6 OP10 12 Nursing procedures must be 12/05/06 carried out in privacy to maintain the dignity of residents. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 25 7 OP29 19 The registered person must keep in the home records relating to each person employed, as listed in schedule 2 of the Care Homes Regulations. (30/11/05 not achieved) The registered person must provide evidence that staff have received training appropriate to their work, including adult protection and fire training. (30/11/05 not achieved) The registered person must provide evidence that staff have received training appropriate to their work, including adult protection and fire training. (30/11/05 not achieved) The registered person must ensure that the home has a manager who is registered with the Commission for Social Care Inspection. The registered person must ensure that residents and staff are protected from fire. The cellar door must be kept locked. The home must display the most recent and current registration certificate. 12/05/06 8 OP18 13, 18 12/05/06 9 OP30 13, 18 12/05/06 10 OP31 8, 9 31/05/06 11 OP38 23 12/05/06 12 13 OP38 *RQN 13 N/A 12/05/06 12/05/06 Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 26 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 Refer to Standard OP7 OP19 OP35 Good Practice Recommendations Care plan documents should be completed in full. Exterior woodwork needs to be re-painted in some areas and a flat roof needs clearing of moss. Records of residents’ personal spending should be maintained accurately and arrangements for making purchases on behalf of residents should be reviewed. Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Thornton Manor Care Home DS0000018787.V289516.R01.S.doc Version 5.1 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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