Inspection on 07/12/06 for Thornton Manor Care Home

This inspection was carried out on 7th December 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 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 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 Unannounced Inspection 7th December 2006 9:30 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 Thornton Manor Care Home DS0000018787.V317629.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.V317629.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 Mr Barry Potton Mrs Pat Bibby Care Home 47 Category(ies) of Learning disability over 65 years of age (1), registration, with number Mental disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (47), Physical disability (10) Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is registered to accommodate a maximum of 47 service users to include: * * 2. Up to 47 service users in the category OP (old age, not falling within any other category) Up to 10 service users in the category of PD (physical disability) Within the maximum of 47, 1 named service user in the category LD(E) (learning disability over the age of 65) may be accommodated until 30 November 2006. Within the maximum of 47, 1 named service user in the category of MD (mental disorder) may be accommodated and the care plan to be reviewed monthly to ensure that the individual’s needs are met and that the placement remains appropriate. 12th May 2006 3. 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. The weekly fee is from £400. Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on 7th December 2006 and lasted six hours. The visit was carried out by one inspector, and an expert by experience was also present. The Commission for Social Care Inspection are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘expert by experience’ used in this report describes a person who has been appointed by Help the Aged, under the direction of the Commission for Social Care Inspection, to take part in the inspection of services for older people. The inspector made a second visit, for one and a half hours, on 8th December 2006 and the arrangements for storage, handling and recording of residents’ medicines were looked at. These visits were just part of the inspection. Before the visit the home manager was asked to complete a questionnaire to provide up to date information about services in the home. Questionnaires were made available for residents and their families to find out their views. Other information received since the last key inspection was reviewed. During the visit, various records and the premises were looked at. A number of residents and their relatives, and a number of staff, were spoken with by the inspector and the expert by experience and they gave their views about the home. What the service does well: Written information about the home is provided for residents and all residents have a contract of terms and conditions. Thornton Manor has a friendly and inclusive atmosphere and 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. Residents have a good diet. 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.V317629.R01.S.doc Version 5.2 Page 6 The home manager has been in post since October 2005 and has completed registration with the Commission for Social Care Inspection. She has given a great deal of commitment to the home and has made a very good impression on residents, relatives and professional visitors to the home in the way that she has raised standards in all areas. What has improved since the last inspection? What they could do better: Make sure that only those residents identified as being at risk of falling out of bed have bed rails, and whenever bedrails are used they must be the correct rails for the bed and must be properly fitted to ensure there are no gaps. The correct fitting should be checked regularly. There is still room for improvement in the standard of recording in residents’ care plans. Nurses should be reminded that tippex must not be used in nursing records. There must be an accurate record of all medicines in the home, including drugs brought in by residents and those carried over from the previous month. Keep a full record of all complaints received including the investigation and any action taken and the outcome. Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 7 There is still room for some improvements in the environment including the flooring in the washing machine room and one of the first floor bathrooms, exterior painting of windows, and replacement of some toilets. It would be helpful for residents if the bathroom and toilet doors were identified with appropriate signs. A bedroom where oxygen is in use should be identified with a warning notice. Make sure that residents’ clothing is taken good care of in the laundry and returned to them. Ensure that kitchen staff have the appropriate protective clothing, including head covering, when preparing food. Sort out the fire folder and make sure that all current information about fire testing, training, and a fire risk assessment are readily accessible. Make sure that bedroom doors are not propped open. 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.V317629.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.V317629.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): 1, 2, 3, 4 and 5. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is provided for residents and all residents have a written contract of terms and conditions. Prospective residents are assessed before admission is agreed. Intermediate care is not provided. EVIDENCE: On 7th December 2006 the home had 45 residents of whom nine were people under 65 years of age and had a physical disability. Since the last inspection, variations to the home’s registration have been agreed with the Commission for Social Care Inspection with respect to two residents who did not fall within the registration categories. The home manager is aware of the home’s conditions of registration and there was no evidence to suggest that any more people had been admitted inappropriately. Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 10 On 8th December 2006 a prospective resident and her family were visiting the home. Written information about the services provided was given to them in a Service User Guide. A member of care staff was been allocated to show them around and the manager was taking this opportunity to assess the person’s care needs to ensure that they can be met at Thornton Manor. For other recently admitted residents, there was evidence in their care plans that they had been visited by the manager, and their needs had been assessed, prior to admission being arranged. The manager confirmed that all residents have a contract of terms and conditions and copies of these are filed in her office and available for inspection. Thornton Manor Care Home DS0000018787.V317629.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has a care plan that details their needs but the standard of recording was not consistent. The health and personal needs of residents are met. Medicines management has continued to improve. EVIDENCE: Five care plans were looked at and showed that the quality of recording was not consistent for all the nurses. The assessments in the first care plan looked at had been poorly filled in and contained contradictory scoring of the resident’s nutritional risk. Tippex had been used on one of the assessment documents. This meant that the scoring was not accurate and is also not acceptable in nursing records. There was no date recorded for when the resident’s regular catheter change is due. There was a care plan for a chest infection that the resident had in April 2006 which did not show whether the chest infection had cleared. Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 12 The second care plan had been completed to a better standard but the recording of wound care for this resident was not very clear and it also had an assessment document that had been tippexed. Two care plans looked at on first floor had been better completed and showed clearly how residents’ health needs were being monitored. Care plans contained a ‘psycho-social risk assessment’ which was not a coherent document, and one of the care plans looked at contained judgemental language that was discussed with the manager. The home has some new equipment including adjustable beds. Pressure relieving mattresses were in use for residents at high risk of developing a pressure sore. A GP who completed a comments card considered that the home is much improved. Residents and their relatives spoken with expressed their satisfaction with their care. The home employs a physiotherapist on a part-time basis and there was evidence of her input in the care plans looked at. The expert by experience spoke with most of the residents and commented that ‘apart from a couple of men who needed a shave and their hair cutting /combing most of the residents, especially the ones confined to their rooms, were presentable. They all said the carers were very helpful and good to them’. It was of concern to observe that a 2 pm three residents had untouched meals still in front of them and this was pointed out to the manager who said that she would find out why. The storage and recording of residents’ medicines were looked at on 8th December 2006. The ground floor medicine trolley was tidy and well organised. The medicine administration record sheets showed that residents received their prescribed medicines at the specified times. The medicine administration records were clear and there were no crossings out and only one unexplained gap. The medicine storage room was tidy and well organised with little excess stock. There was little use of controlled drugs, but controlled drugs that were in use were stored and recorded appropriately. Additional controlled drugs storage had been added since the last inspection. There was only one area where the management of medicines fell short of the required standard. The quantities of medicines, for example pain killers that are given as needed, were not carried forward from one month to the next. This means that the home is not keeping an accurate record of all medication which is held in the home in order to provide by means of an audit trail that all medication is accounted for. Similarly, the quantities of drugs brought into the home by a new resident had not been recorded. Thornton Manor Care Home DS0000018787.V317629.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social opportunities are provided for residents and they are able to exercise choices in daily living. A good variety of meals is provided. EVIDENCE: A comments card received from relatives said that the home is very good at taking residents out for social visits. A minibus and driver are available and some residents are taken out regularly to visit their family, to go shopping or to attend social events. Some residents are supported to attend daytime placements and take part in continuing education. One resident had been allowed to bring his dog with him another has a cat. The expert by experience found that these did not seem to present a problem for other residents or with the cleanliness of their rooms. Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 14 The expert by experience asked residents about activities and they all seemed to think they did them, but other than making Christmas cards for the forthcoming fayre, and necklaces and beads for the Autumn fayre, they couldn’t tell her whether they were on a regular basis, although one resident said that they would be doing baking that afternoon. A resident said that they used to have Bingo but they don’t now. They remembered going to see the illuminations at Blackpool. The mobile library sometimes called. One of the ladies in her bedroom had just had her hair done. At 10 am residents were having breakfast in dining room. One resident told the expert by experience that she wanted her breakfast at 8 am but she would go into the dining room at 9 am and it wasn’t served until 9.45 am. Residents can have a cooked breakfast, or cereals and toast. The assistant chef has been promoted to head chef and introduced new menus that are more interesting and varied for residents, from 1st December 2006. The expert by experience had lunch with the residents in the downstairs lounge and made the following comments: The tables were laid with tablecloths and napkins with a small posy of fresh flowers. There was minimal cutlery, which seemed to be mismatched, dessert spoons were laid for pudding and I had to ask for a teaspoon for my yoghurt. The cruet set on my table had smears of ketchup and needed cleaning. Plastic beakers with orange juice were on each table and cold water was available from a wall dispenser. The trolley was set with teacups for either tea or coffee. A couple of people were in wheelchairs. The lunch was braised steak with onions and mushrooms, roast potatoes and green beans. The portions of steak were generous. Semolina pudding with jam to follow or yoghurt. No-one needed to be fed and the carers went around to cut up the food if this was required. A few did struggle to eat their food (because of handling disabilities) but everyone seemed to enjoy it. On speaking to the chef after lunch he was anxious to know whether the steak was cooked enough and I assured him it was fine and tasty. The alternative was jacket potato with fillings. The evening meal was a plate of various sandwiches or chicken skewers. There was a whiteboard which displayed the meals and alternatives for that day and the names and dates of forthcoming birthdays when they celebrated with cakes. The chef asked the residents the day before what they would like the following day. He was not wearing a kitchen uniform. Tea/coffee was served in the afternoons, Horlicks etc with biscuits or toast was served for supper. Thornton Manor Care Home DS0000018787.V317629.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously but not always recorded in full. Staff have now completed training about the protection of vulnerable adults. EVIDENCE: Complaints received at the home are recorded in a complaints folder. The manager provided information that three complaints had been made to her since the last key inspection. These had been recorded but not in sufficient detail. One complaint had been made by a member of staff, and it is a positive reflection on the home that the complaints procedure can be used by staff. The Commission for Social Care Inspection has received no complaints about Thornton Manor since the last key inspection. In June 2006 training about the protection of vulnerable adults was provided for 13 staff and the manager said all staff have now completed this training. Policies and procedures have been updated to reflect local and national guidance. Thornton Manor Care Home DS0000018787.V317629.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, 24 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 the environment has continued to improve and residents are satisfied with their accommodation. EVIDENCE: The general impression of the home is that it is cleaner, tidier and more comfortable. Investment has been made in new equipment for the benefit of residents. This includes a new call system and two sluicing disinfectors. The expert by experience commented that: The reception area was quite cheerful with a Christmas tree and other decorations. The bedrooms I entered to speak to the residents were adequate but some of them hadn’t enough drawer or cupboard space, clothes etc were waiting to be put away and some of this furniture was mis-matched (unless it was the residents own furniture). There was a general feeling of untidiness. The larger rooms were brighter and tidier. All of the rooms were personalized . Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 17 A garden area has been developed with raised beds and a greenhouse that have been designed for residents to be able to use safely. There is also additional car parking. A tour of the building showed that there are still some improvements needed. The flooring in the washing machine room and in one of the first floor bathrooms needs attention/replacement. Some of the toilets are damaged around the base and this makes it difficult to thoroughly clean and disinfect them. It would be very helpful for residents if the toilets and bathrooms were clearly identified by signs on the doors. Repairs and repainting of exterior woodwork has not yet been completed. Bedrails were in place on the beds in a number of residents’ rooms and it was of serious concern that several of the rails had not been correctly fitted. This resulted in a considerable gap between the end of the rail and the head of the bed. This means that a resident could get their head/neck trapped in this gap with potentially serious consequences. This was pointed out to the manager and an immediate requirement was made. The manager took prompt action to address the situation and ensure that staff were made aware of the danger. A full review of all the rails currently in use is needed and any that are not fit for purpose should be replaced. Some concerns were raised by relatives about the care of residents’ clothing. At the time of the visit the home employed only one laundry assistant and was trying to recruit a second person. It appeared that when the laundry assistant has her days off, the staff covering in the laundry did not always follow the correct procedures for the care of residents’ clothing. A relative visiting complained that her relative never seemed to be dressed in his own clothes; he had always been a smart man and had never worn short sleeves before. She was sure that he did have name tags in his clothes. On one occasion she had brought him a sweater that she had knit herself and it had been put into the washing machine and had shrunk. Thornton Manor Care Home DS0000018787.V317629.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs enough staff to meet the needs of residents. Recruitment practices have been made more robust and training is provided for staff. EVIDENCE: From observation during the visit, and looking at staff rotas, it was evident that an appropriate number of nurses and care assistants are on duty to ensure that residents needs are met. It was noted that some overseas staff are working up to 72 hours in a week. This was discussed with the manager who was aware that this appears excessive but had found no problems with the performance of the staff who work a lot of hours. The recruitment records for recently employed staff were mainly satisfactory and all staff had a current Criminal Records Bureau disclosure. However for one member of staff there was no reference from the last employer but there was a reference from the next door neighbour, which is of questionable value as an employment reference. Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 19 Records showed that staff training had been taking place throughout the year. The training matrix was not complete so it was not possible to see, without going through individual files for each member of staff, whether every member of staff had received training in mandatory subjects relating to the health and safety of residents. Most staff attended fire safety training in July 2006 and some staff had moving and handling training in September 2006. The home employs a physiotherapist on a part-time basis and she is able to provide moving and handling training for the staff. Drivers have attended minibus safety training. Some staff have attended dementia care training and food hygiene training. There is an induction programme for new staff and all carers have been given a copy of the General Social Care Council code of conduct. The manager said that a new staff handbook is being produced. More than 50 of the care staff have achieved a national vocational qualification in care or equivalent. Thornton Manor Care Home DS0000018787.V317629.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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a competent and experienced manager who has worked very hard to improve standards in all areas. The safety of residents was at risk from badly fitted bed rails. EVIDENCE: The manager has been in post since October 2005 and has completed the registration process with the Commission for Social Care Inspection. The manager has been asked to also oversee a domiciliary care agency that is based at Thornton Manor. This must not divert her time and energy from the care home. There remain some organisational tensions for the manager to deal with, however she has retained her commitment and enthusiasm and continued to take the home forward. Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 21 A comments card from a relative said ‘The manager has done her utmost to bring this care home up to the required standard. She has also worked tirelessly to provide additional amenities/activities for all residents.’ Satisfaction surveys have been carried out in May and October 2006 and a lot of positive comments have been received as well as some areas for improvement. Regular meetings are held for staff and residents and these are all minuted. From looking at the minutes it was clear that staff have the opportunity to raise any issues of concern to them. The manager audits medicines and care plans and there are regular visits by the proprietor. The manager provided information about when plant and equipment had been tested and serviced. The fire alarm system is tested weekly, the emergency lighting monthly, and the hot water monthly, by the home’s maintenance person. The fire records were not complete and the folder needs sorting out as it contains records going back to 1997. Extinguishers had been checked in September 2006 and smoke detectors in October 2006. The fire officer visited in May 2006 but the manager said that she has not had a copy of his report. She was unable to find the fire risk assessment. Concerns about the safety risk from incorrectly fitted bedrails have been detailed in the ‘Environment’ section. Some bedroom doors were propped open and some bedroom doors do not swing closed properly. A bedroom where oxygen is in use should have a sign on the door to indicate this. Kitchen staff were not wearing appropriate protective clothing and did not have their hair covered when preparing food. Thornton Manor Care Home DS0000018787.V317629.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 3 3 3 3 3 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 3 X 3 X x X X 1 Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 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 OP38 Regulation 13(4)(c) Timescale for action Make sure that only those 07/12/06 residents identified as being at risk of falling out of bed have bed rails, and whenever bedrails are used they must be the correct rails for the bed and must be properly fitted to ensure there are no gaps. The correct fitting should be checked regularly. There must be an accurate 14/12/06 record of all medicines in the home, including drugs brought in by residents and those carried over from the previous month. Ensure that kitchen staff have 14/12/06 the appropriate protective clothing, including head covering, when preparing food. Make sure that fire records are 14/12/06 complete and that staff do not prop fire doors open. Requirement 2 OP9 13(2) 3 OP38 16(2)(j) 4 OP38 23(4) Thornton Manor Care Home DS0000018787.V317629.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. 2 3 Refer to Standard OP7 OP16 OP19 Good Practice Recommendations Nurses should be reminded that tippex must not be used in nursing records. Keep a full record of all complaints received including the investigation and any action taken and the outcome. Continue improvements in the environment including the flooring in the washing machine room and one of the first floor bathrooms, exterior painting of windows, and replacement of some toilets. A bedroom where oxygen is in use should be identified with a warning notice. Make sure that residents’ clothing is taken good care of in the laundry and returned to them. 4 5 OP38 OP10 Thornton Manor Care Home DS0000018787.V317629.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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.V317629.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. Re-publishing this information is in breach of the terms of use of that website. 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