Inspection on 26/06/08 for Thornton Manor Care Home

This inspection was carried out on 26th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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 11/07/07

Thornton Manor Care Home 07/12/06

Thornton Manor Care Home 12/05/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Thornton Manor Care Home Thornton Green Lane Thornton Le Moors Cheshire CH2 4JQ Lead Inspector Wendy Smith Unannounced Inspection 26 June 2008 10am 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.V367187.R01.S.doc Version 5.2 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.V367187.R01.S.doc Version 5.2 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 patb@casicare.com Mr Barry Potton Mrs Patricia Bibby Care Home 47 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (47), Physical disability (47) Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care home with nursing: Code N The registered person may provide care to people whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP Physical Disability: Code PD Learning Disability (over 65 years): Code LD(E) (maximum number of places 1) Dementia (over 65 years): Code DE(E) (maximum number of places 1) Gender: either The maximum number of people who can be accommodated is 47. 11 July 2007 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 people with a physical disability. There are bedrooms, bathrooms and communal areas on the ground floor and the first floor. The second floor is used as office accommodation. 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. The weekly fee currently paid by residents is from £367.54 to £618. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Two inspectors made an unannounced visit to Thornton Manor on 26 June 2008. There were 34 people living at the home at the time. During the visit we spoke with residents, staff and visitors. CSCI survey forms were sent out before the visit to give residents, relatives and staff the opportunity to let us know their views about the home. Before the visit, the manager was asked to complete a questionnaire to provide us with up to date information about the home. Some of the comments we received and the information we were given are included in the report. A tour of the building, including all communal areas and some bedrooms, was completed. A sample of records was looked at and time was spent talking with the home manager. What the service does well: Thornton Manor has a friendly and inclusive atmosphere and caters for the individual needs of a diverse group of people. Relatives are encouraged to be involved in the day to day life of the home. Transport is available for residents to go and visit family members, to go out shopping, to attend daytime placements and for social outings. Relatives may also book the minibus to bring them to the home. Residents are encouraged and supported to pursue their hobbies and interests to keep them active and stimulated. Residents have a good diet and the menus are adapted to suit the preferences of residents. Whenever possible fresh produce is used so that the people who live in the home receive nutritious food. The home provides nurses and care staff in sufficient numbers to ensure that the needs of residents can be met in full. More than 50 of care staff have a qualification in care. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Records of assessments carried out before a new person comes to live at the home should be signed and dated by the person completing the form to show who did the assessment and when. Care plans continue to fall below a satisfactory standard and fail to provide evidence that residents’ health is monitored or that identified risks are managed to ensure their health and safety. Care plans should include an assessment of residents’ social and emotional needs and plans to make sure that these needs will be met. The current practice of keeping medicine trolleys in communal rooms should be reviewed to ensure that medicines are stored securely at all times. Bedroom furniture that has become shabby, and flooring in en-suite facilities that is marked, should be replaced so that all residents have a bedroom of a good standard. An area of the first floor corridor carpet requires attention to prevent it becoming a trip hazard. The arrangements for smoking should be reviewed to make sure that the home complies with smoke free legislation (2007) as it affects care homes to protect residents from the harmful effects of smoke. Staff must not start working in the home until two verifiable written references have been obtained for them. This is to make sure that residents are protected from possible harm or poor practice. The training records and chart should show when staff have completed mandatory training to make sure they have completed all the necessary training so they know how to carry out their work safely. Audits of care plans needs to be more thorough and in depth so that shortcomings are identified and addressed with the nurses. A monthly audit of accidents is recommended as good practice, as this would help to identify when and how accidents are occurring and whether any action can be taken to reduce accidents. The annual quality assurance assessment indicated that there are some gaps in the home’s policies and procedures, which provide guidance for staff; for Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 7 example, visits by family and friends, discharge of service users, first aid, induction and foundation training, pressure relief, racial harassment. Recommendations for good practice to improve the service were made at our last big inspection in July 2007. It is disappointing to find that most of these recommendations have been repeated following this visit. The home owner should consider whether it is in the best interests of Thornton Manor Care Home and the people who live there for the home’s manager to be also managing another service. This situation has continued for a considerable length of time. 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. The summary of this inspection report can be made available in other formats on request. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 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.V367187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable to this service) People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People interested in coming to live at Thornton Manor have a full assessment to ensure that their care needs can be met at the home. EVIDENCE: On the day of our visit there were 34 people living at the home. Ten of these were people under 65 years of age who have a physical disability. Three were older people receiving personal care, and 21 older people receiving nursing care. The information we were sent by the manager before our visit stated that 14 residents have dementia, but they also have general health conditions. One person has mental health needs and two have a learning disability. The home manages to integrate a wide diversity of people. Before people go to live at Thornton Manor their needs are assessed by a senior nurse from the home. The care plan that we looked at, for person who had moved into Thornton Manor in May 2008, contained an assessment Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 10 document which was fully completed and detailed. However, the nurse who filled in the form had not signed and dated it, so it was not possible to check when the assessment had taken place or which nurse had assessed the resident. (This was also commented on at the last inspection in July 2007.) The care plan also contained information received from the hospital where the person was cared for before going to Thornton Manor. Relatives of a new resident commented: We have been very impressed by the homely and friendly attitude of the staff and have been made very welcome. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. In general the care needs of residents are met, but records do not show that residents’ health is monitored or that identified risks are managed to ensure that the health and safety of residents is protected. EVIDENCE: Each resident has a care plan folder that contains assessments of their needs and plans for how their needs should be met. We looked at four care plans and only one of the four met the standard that we would expect. The others did not give guidance to staff who were caring for the resident to enable them to know what their needs were and how to meet them. Similar findings were made at our last big inspection in July 2007. One of the folders was so full of old documents that it was very difficult to find any up to date information about the person and the care she was receiving. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 12 Risk assessments had been completed, but the moving and handling assessments were difficult to understand. Nutrition risk assessments that identified that a resident was at high risk were not followed up with a care plan or with referral to a dietician. Two people whose care plans identified that they were at high risk of malnutrition had not been weighed recently. A risk assessment for the use of bedrails was dated December 2006 and was no longer relevant to the person’s needs. Recording of wound care was inconsistent and did not always show what dressings were currently in use. For one person, the type of dressing had been changed several times but there was no information to show why the changes had been made or who had made the decision. There were no photographic records - this is often a helpful way of recording wound progress. Equipment is provided to meet people’s needs. A number of the more frail residents have an adjustable bed and there are pressure relieving mattresses for people at risk of pressure damage. There is a number of different types of moving and handling equipment, and residents used various types of mobility aids. The home provides a physiotherapy service. In the shower room on the first floor, a set of drawers contained various toiletries, brushes and combs that were not identified as belonging to any resident. Such items should not be shared. Residents and their visiting relatives told us: the staff are really nice: the staff are like our friends, nothing is too much trouble: I like living here: I am very happy at the moment. No residents were looking after their own medication but the manager said that an assessment is available for anyone who wishes to do this. Medicine administration records were good, with no missed signatures, and handwritten medicine administration record sheets were satisfactory. Controlled drugs were stored and recorded appropriately. There was a medicine trolley in each dining room throughout the day. Neither of these was secured to a wall which meant that the storage of the medicines was not adequately safe. There was a medicine pot containing an unidentified white tablet in the door of one of the trolleys. For one resident there was some discrepancy in the quantities of two medicines that had been carried over from the previous month. The dosage of one of these drugs had been changed on the medicine administration record sheet but there was nothing to show who had authorised this and when. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Residents are able to exercise choices in daily living and can participate in social activities both inside and outside of the home so they can keep active and stimulated. EVIDENCE: The home does not have an activities organiser at present but the staff maintain a programme of activities and social events to include as many residents as possible. Residents receive support to pursue hobbies and interests. There is plenty of equipment for activities. Notice boards throughout the home advertised a barbeque to be held at the home and to which visitors were invited. Staff bring in daily newspapers for residents. A new garden area was developed in 2006 and this is set away from the building. Residents can go and sit in the garden on their own if they are able, or with visitors. The garden and greenhouse are also used for activities. A minibus is used to pick up relatives and to take residents out. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 14 The social and emotional needs of residents are not reflected in their care plans and a ‘life story’ of each person might be beneficial in helping staff to understand their needs. Most residents have brought in a lot of their own belongings to make their bedrooms more personalised. The menus are continually adapted to suit the preferences of residents and people spoken with all said that they enjoy their meals and the food is very good, varied and plentiful. There is always a choice. The lunch served on the day of the visit was of a good standard and fresh produce is used as much as possible. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. Residents are protected by the home’s policies and procedures about complaints and safeguarding, but records do not show that all complaints have been addressed in a satisfactory way to make sure that residents’ concerns are listened to. EVIDENCE: The home has a complaints procedure and the manager keeps a record of complaints received. There was no record of a complaint that was sent to the provider in July 2007 and no evidence that it was investigated by the provider. Two complaints had been logged in the complaints register. A list of what the complaint was about had been recorded and letters that had been sent to the complainants were in the file; however, the details of the complaints, timescales and actions taken need to be more thoroughly logged to enable the complaint to be tracked more clearly. Most staff have received training about the protection of vulnerable adults and the prevention of abuse and policies and procedures are in place for guidance. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. The maintenance of the home is sufficient to make sure that residents live in a comfortable and safe environment, but communal areas are crowded and some bedrooms need improvement. EVIDENCE: The grounds of the home are pleasant and well-maintained and there is plenty of parking space. There have been some improvements to the interior. The ground floor dining room has been changed into a lounge and has new chairs. It is comfortable but overcrowded with furniture. The ground floor lounge has been re-decorated and changed to a dining room with six dining tables. This room is also overcrowded with furniture. Many of the people who live at the home are wheelchair users and need enough space to move around. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 17 The carpet in the ground floor corridor is quite new but parts of it are marked by wheelchairs and trolleys. Some bedrooms have been redecorated and some have new furniture, but other bedrooms are shabby with mismatched furniture and marked flooring in the en-suite toilet. The manager should make an inventory of all bedroom furnishings and agree a programme of replacement with the provider. Bathrooms have been made more pleasant but the bathroom on the ground floor is used for equipment storage and does not look inviting for people to use. An area of the first floor corridor carpet is wrinkled following water damage and needs to be repaired to ensure that it doesn’t trip someone. A room at the end of the ground floor corridor is used as a smoking lounge for residents. The door was open and smoke was wafting down the corridor past other people’s bedrooms. This is in contravention of smoke free legislation (2007) and should be addressed without delay. Replies received to a recent satisfaction survey indicated that not all of the residents and/or their relatives are happy with the cleanliness of the bedrooms, though most are. On the day of the visit the home was generally clean, but there was a problem with a cat litter tray in a stairwell. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. Enough trained and qualified staff are provided to meet the needs of the residents, but recruitment checks are not always thorough enough to make sure that residents are protected from possible harm. EVIDENCE: Five nurses and 18 care assistants are employed at the home. More than half of these are overseas staff. However, there were no apparent communication difficulties between staff and residents. Staff rotas showed that there are enough staff on duty by day and night to meet the needs of residents. Information provided by the manager indicated that more than 50 of care staff have a national vocational qualification in care or equivalent. Two new staff have been employed since the last inspection and neither of these people had references that were acceptable. For one person there were two letters of reference that had both been written to ‘To whom it may concern’ and do not specify that they relate to employment at Thornton Manor. For the second person, the application form did not make clear when the person’s last employment had ended which means that there could be an unexplained gap in employment. The names of two referees were given but it Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 19 was not clear what position these people held, and for one there was just a name. The references on file did not clarify on what basis they were qualified to give a reference. Records showed that staff have attended a variety of training courses over the last year. The manager keeps an annual training record which has a tick when training has been completed. More detailed training records need to be kept to show on what date staff have received the training and when they are due for an update. There is a significant amount of crossover between staff working for the domiciliary care agency which is owned by the same company, and training records did not identify that they had received training about working in a residential setting. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home has a competent and experienced manager but over the last year good practice recommendations have not been addressed and the home has not moved forward to make sure that it is run in the best interests of the residents. EVIDENCE: The manager has been in post since October 2005 and since then she has made great improvements to the home. In the last year she has completed the registered manager award. For a considerable period of time the manager has also taken responsibility for the domiciliary care agency that is based at Thornton Manor. We were concerned that this has diverted her time and Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 21 energy away from the care home and the situation should be addressed by the home owner. The information sent to us before our visit provided little information about how the benefit of the people who live at the inaccuracies; for example, it stated that no the last year. was not completed in detail and it service will be developed for the home. There were also some complaints had been received over There was evidence of some quality auditing of care plans and medicines. The manager had looked at a sample of care plans each month but there were no details of her findings and how any shortcomings had been addressed, and three of the four care plans that we looked at were not satisfactory. There was no evidence that accident forms are audited to see whether there are any trends in when or how accidents occur. There was no evidence of the monthly visits by the provider that are required by regulation 26 of the Care Homes Regulations. A customer satisfaction survey was being carried out. Residents are able to keep small amounts of personal spending money in the home’s safe. The records looked at showed that all expenditure was accounted for and recorded. The information we were sent included information about when plant and equipment had been tested and serviced. The home’s maintenance person tests the fire alarm system weekly, the emergency lighting monthly, and the hot water monthly. The fire records showed that regular fire drills are held and the names of staff attending were recorded. The information the manager sent us before the inspection indicated that there are some important areas where the home does not have written policies and procedures for the guidance of staff. These included first aid, induction and foundation training, pressure relief, recruitment, racial harassment, sexuality and relationships, working with volunteers. Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 X 18 3 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 2 X 3 X X 3 Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The medicines trolleys must be stored securely to make sure that the medicines kept in them are kept safely. Timescale for action 02/07/08 2 OP16 22(3) Complaints made under the 02/07/08 complaints procedure must be fully investigated and a written record must be kept to show that this has happened. The record must show the details of the complaint, the investigation, outcome and that the complainant has been notified of the outcome. This is to ensure that people’s concerns are listened to and their complaints are dealt with. New staff must not be employed in the home until two satisfactory references are received to ensure that they are suitable to work in care and the residents are protected from possible harm. 02/07/08 3 OP29 18 Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 24 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 OP3 Good Practice Recommendations Assessments carried out before a person moves into the home should be signed and dated to provide a record of which nurse has done the assessment and when. Care plans should provide evidence that residents’ health is being monitored and that identified risks to the health and safety of residents are managed. Auditing systems must be thorough and in depth so that any shortcomings in care plans are identified and addressed with the nurses. The bedroom furniture that has become shabby should be replaced so residents live in more pleasant surroundings. Steps should be taken to make sure the home complies with the smoke free legislation (2007) as it applies to care homes so that residents are protected from tobacco smoke. The training records and matrix should show when staff have completed mandatory training so it is clear when they are due for an up-date. Monthly audits of accidents should be carried out to identify when and how accidents are occurring and whether any action can be taken to reduce accidents. For the guidance of staff, policies and procedures need to be developed for first aid, racial harassment, and other subjects that identified in the annual quality assurance assessment as not being in place. 2 OP7 3 OP33 4 5 OP24 OP38 6 OP30 7 OP33 8 OP37 Thornton Manor Care Home DS0000018787.V367187.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North West Region CSCI Preston Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V367187.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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