Inspection on 23/07/07 for Threshfield Court

This inspection was carried out on 23rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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

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Larchfield Manor

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The Grove Waltham

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Carentan House

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

CARE HOMES FOR OLDER PEOPLE Threshfield Court Station Road Threshfield Skipton North Yorkshire BD23 5ET Lead Inspector Caroline Long Unannounced Inspection 09:30 23rd July 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 Threshfield Court DS0000069346.V348265.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. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Threshfield Court Address Station Road Threshfield Skipton North Yorkshire BD23 5ET 01756 752200 01756 752666 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) Barchester Healthcare Homes Ltd Mrs Valerie Gains Care Home 61 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (37), Physical disability (37), Physical disability over 65 years of age (37), Terminally ill (4) Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. OP, DE(E) and MD(E) Age 60 years upwards Service Users in the category PD should be: I) aged 50 years plus and ii) require nursing care. Date of last inspection Brief Description of the Service: Threshfield Court offers nursing and personal care for up to sixty-one people with general nursing needs, physical disabilities, dementia, and mental disorder. The home is situated in the small village of Threshfield close to Grassington in the Yorkshire Dales. The nearest town is Skipton. The home is a large detached building with accommodation on three floors, and a passenger lift to all the floors. Most of the bedrooms are en-suite. The home has large attractive well-maintained gardens and car parking. The weekly fees range from £600 plus the contribution for nursing care made by the National Health Service. This does not include costs for items such as hairdressing or chiropody. The registered manager supplied this information to the Commission For Social Care Inspection on the 10th August 2007. Inspection reports are available by requesting them from the home. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is what was used to write this report. • • • Information about the home kept by the Commission for Social Care Inspection. Information asked for before the inspection, this is called a pre inspection questionnaire. Information from surveys that were sent to people who live at the home, their relatives, health professionals and the staff. Six surveys were returned from people who live at Threshfield Court and four were received from relatives, two from General Practitioners and four from health professionals. An unannounced visit to the home. This was carried out by one inspector and lasted over seven hours and included talking to staff and the registered and deputy managers about their work and the training they have completed. And checking some of the records, policies and procedures the home has to keep. Some time was spent observing staff supporting people and talking with the people who live at Threshfield Court. Four peoples records were looked at in detail. Where some of the records were fully inspected at the inspection carried out in December 2006, these have not been looked at during this inspection. • • • • Although the home is registered to take younger adults who have a physical disability, the registered manager explained they only take up to two people from the local community to stay for a short time, whilst their carers have a break. She explained how this service helps people to remain near to their friends and families and gives the carers a rest. During the inspection, there was no one under the age of sixty-five in the home. What the service does well: The home is managed in a manner that puts the people who live there first. It concentrates on their needs, wishes and views. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 6 Threshfield Court offers a place for younger people with a physical disability to stay temporarily near to family and friends whilst their main carers have a rest. People are provided with enough information and given the opportunity to stay at the home before they move in permanently. This helps them make an informed decision about whether Threshfield Court is the right place for them to live. The staff are aware of the major life change moving into Threshfield Court is for people and are prepared to give the extra support needed to help them settle into the home. The home has a specialist unit which cares for people with dementia that has been awarded the Independent Healthcare Award for Innovation in Dementia Care. This shows the home promotes good practice and this will result in a better quality of life for people with dementia. All the staff in the home receive training about how to help people with dementia, this means they are all confident in meeting, greeting and talking with people on the Memory Lane Unit in a friendly and positive way. People are encouraged to be independent and make choices about how they want to live their lives. The home has a warm friendly atmosphere, where people are encouraged by staff to participate in social activities of their choice. There are various outings arranged and in house activities, which allow people contact with the local community and provide stimulation. Visitors are encouraged and made welcome. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 only. People who use the service experience excellent quality outcomes in this area. People are provided with good information about home and their diverse personal needs are identified and planned for before moving in, this makes sure Threshfield Court is the right place for them to stay. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The registered manager and deputy manager explained a member of the management team visit anyone who is considering moving into Threshfield Court. They visit them at their home to carry out an initial assessment of their needs and to provide them with information about the home. Following this they are invited to visit Threshfield Court to experience the lifestyle and find out if it is the right place for them to live. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 9 Two peoples’ records who had recently been admitted to the home were looked at in detail; both contained an initial assessment, which had been carried out in the person’s home. This information had the necessary details to give a good indication of their care needs and would have enabled the staff to assess whether they were able to meet people’s preferred or specialist needs. It included the recordings of personal preferences, which showed people were being fully consulted about the move. One person living in the home was able to confirm they had visited Threshfield Court and stopped for a weekend and had been given information about the home before moving in. Also surveys received from people living in the home and their relatives generally indicated people had received enough information before moving in comments made were: ‘Very efficient.’ ‘Very communicative and helpful staff.’ Staff said before people move in they are allocated a key worker who prepares the room with fresh flowers from the garden for their arrival. Also, they made sure it had been cleaned thoroughly, and the nurse call system and the TV remote were working. On the person’s arrival they would help them unpack and check on them regularly, providing the time for them to ask questions about the home. The staff indicated they were aware of the major life change moving into Threshfield Court was for people and how they needed reassurance and time to adjust to their new surroundings. Staff confirmed they receive the training they need to provide the necessary support and care for the people living in the home. On the Memory Lane unit, all the staff had undertaken training in dementia care. Three people who returned their surveys said they had received a contract, the registered manager confirmed there have been no changes made to the contract following the site visit in December when they were inspected. The home does not provide intermediate care. Although the home is registered to take younger adults who have a physical disability, the registered manager explained they only accommodate up to two people from the local rural community who stay temporarily for an average of ten days. She explained how this service helps the people to remain near to their friends and families and gives the carers a rest. As they are only resident for a short time the care is tailored to their individual needs and for continuity, Threshfield Court would try to follow the same routines as the person would have in their own home. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 10 Two rooms were specifically kept for this service, which are both on the ground floor, are larger than normal and have en-suite facilities. The one looked at during the site visit had a small sitting area and a dining table. It also had access to the garden and a private terrace with a table and chairs. The deputy manager explained this gives the younger people the choice of remaining separate from the main home. Threshfield Court DS0000069346.V348265.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): Standard 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. People are treated with respect and dignity by the staff and they receive personal care based on their individual needs. However, the managers need to continue to strengthen the records and medication practices to make sure people are kept safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There have been positive comments made by people both on the surveys and during the site visit about the care people receive. Examples are: ‘Very proficient staff, good all round care.’ ‘Good physical care, cheerful atmosphere pleasant relationships between staff and kind and often affectionate treatment of residents.’ ‘Couldn’t ask for anymore.’ Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 12 During the site visit in both units staff were observed providing personal care and responding to requests for help with warmth and in a kind, considerate way. Personal care was offered in a manner, which was respectful and promoted peoples’ dignity. Staff were able to give examples of how they would make sure people retained their privacy and dignity. Two peoples’ case records from the Linton unit and two from the Memory Lane unit were looked at in order to check plans were in place that would help staff provide support and nursing care to people in the home according to their needs and wishes. The homes plans were found to be person-centered care, this means caring for the whole person, enabling each individual to make the most of his or her remaining abilities and continue to be socially active. For all the records looked at, an initial assessment was carried out when the person first moved into the home. Where a need was identified at this assessment, a plan of the care was commenced, these covered personal hygiene, communication, mobility and dexterity, mental health and cognition, breathing, sleeping, pain, religious and social interests, relationships hopes and concerns for the future. These plans were supported by risk assessments for nutrition, tissue viability, mobility and dexterity, and falls. All identified both the persons nursing needs and personal care needs in detail, and their personal preferences. The information recorded also showed how people were consulted about their care plans by the staff. The care plans and risk assessments had been reviewed regularly. Staff explained how the nurse-in -charge would go through the care plan when someone new came into the home and also how they would read through the plans to update themselves following their holidays. The registered manager explained the format of the care plans was new and staff were at present identifying issues with them and finding the best ways to use them. This was apparent, as although the plans fully described the preferred needs of people they did not always have the actions the staff needed to take to provide the care. Also, staff had not yet worked out how and where to record any changes. However the staff were expecting a visit by the area clinical nurse specialist and they hoped to be able discuss and resolve these issues soon. People living in the home during the site visit were observed to be clean and well cared for and dressed appropriately according to their preferences. The registered nurses meeting recorded how staff were asked to make sure they entered in the care plans peoples preferences about how their hair, nails and teeth. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 13 Peoples health care needs are promoted and maintained. When a person is admitted their nutrition, and tissue needs are assessed. If the assessment indicates any specialist needs these are monitored, added to their care plans and a referral is made to the appropriate health professional. The records showed people were accessing health care professionals, such as GP’s, chiropodists, physiotherapists, occupational therapists, dieticians and district nurses. The people who live in the home and their relatives’ surveys also confirmed they receive the medical support they need and relatives were always kept informed. There is a medication procedure to guide the staffs practice and training is provided on safe storage, administration and disposal of medicines. A sample of medication was checked in both of the units. In one where a person was asleep at the time medication was administered it had not been given, also for another person the records showed they had taken their medication but checks evidenced this medication had not been given. The registered and deputy managers were informed and immediately took action to resolve this issue and to make sure the medication practices were safe and people were getting the medication they needed. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use this service experience excellent quality outcomes in this area. People have the lifestyle they choose. Staff provide opportunities for their social, cultural and recreational expectations to be met and people are given a varied diet, according to their choice. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People confirmed they choose their own daily routines and are encouraged to remain independent and have as much control over their lives as is possible. There are activities organisers for both units’ one full time for the Linton unit and two part-time for the Memory Lane Unit. All the care records have information about people’s preferred, social activities and interests, and in the Memory Lane unit, detailed life histories had been completed. This informs the staff and makes it easier for them to help people continue their hobbies and interests when they are living in the home. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 15 The site visit, the records and the newsletter showed there is a extensive range of activities for people to join in if they wish, such as a choir, art, card games, karaoke, music and gardening. Trips out to local places of interest and lunch at local public houses. People living in the home said they enjoyed the activities on offer and there was no pressure to join in. During the site visit people on the Memory Lane unit were being encouraged to help with the daily living tasks such as washing up and setting the tables, others were playing dominos, some were walking up and down the unit but most appeared calm and contented. The corridors of the unit are covered in photographs and memorabilia for people to look at and touch. There are enclosed gardens for people to use. When asked what Threshfield Court does well a relative commented: ‘Interaction with residents, reading, playing games, singing, baking, getting them to clean shoes, wash-up, doing their nails, trying to keep life as normal as possible.’ Staff were observed welcoming visitors into the home, special thought had been taken to enable people living in the home to feel comfortable when asking friends to visit and dine with them. There is a newsletter produced to inform of any forthcoming events and achievements within the home. It has a regular update on the developments of the registered managers Labrador puppy, which she hopes will become a familiar friend for everyone in the home. There are three main meals per day and a choice is provided at each. Menus were looked at and these were varied. Special dietary needs such as low sugar diets are catered for and special requests can usually be met. People generally spoke positively about the quality of meals provided and people said they enjoyed their lunch. The registered manager explained staff have started sitting with people to eat on the Linton unit and the Memory Lane unit they believe this helps to make the meal more of a sense of occasion and makes the unit feel more of a home. During the site visit staff supported those people who needed assistance respectfully and discreetly. Comments made by relatives were: ‘The meals are well presented and varied and a lot of effort is taken to encourage residents to eat them.’ Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use this service experience good quality outcomes in this area. People can be confident that concerns are listened to and appropriate action is taken. There are sufficient effective systems in place to safeguard people from harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The complaints policy is given as part of the welcome pack to people who live in the home. During the site visit, people generally gave the registered manager and the deputy as the people they would speak to if they had any concerns or complaints. People who use the service also generally stated in the surveys they were aware of how to make a complaint. The manager deals with general day-to-day complaints and anything more serious is passed to the organisation’s quality assurance manager to investigate. The home records concerns so they can identify if there are any recurring issues and then uses this information to improve the service provided. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 17 The Commission has not received any complaints about the home and only one concern had been recorded since the last inspection about the washing of clothes and a drink, these had been investigated by the registered manager and resolved. The home has a copy of the North Yorkshire County Council Safeguarding Adults procedure and staff talked with were generally aware of the steps to take if they suspected abuse. Many of the staff said they had recently completed protection of vulnerable adult training. However, discussion with staff and the deputy manager showed this training needs to be constantly reinforced to make sure everyone is fully aware of the need to alert if any type of abuse is suspected. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 18 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): Standards 19 and 26. People who use this service experience good outcomes in this area. People live in a clean, comfortable and safe home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: On the day of the site visit the home was fresh, clean, warm and welcoming. People who live in the home and the staff said this was usually the case. The staff promote a homely feel to the home through the decorations and the flowers. The home is on three floors, which are accessible by a passenger lift; one part has been specially adapted for people with dementia and is called Memory Lane. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 19 There are beautiful gardens, which have won various awards and are specially adapted for people with dementia. During the site visit, people said how much they enjoyed walking in the gardens and watching the wildlife. Memory Lane is decorated to a high standard and has photographs and displays on the walls, which are aimed at helping the person feel they are in comfortable and familiar surroundings, and to help them find their way independently to their bedrooms. There is a joint lounge and dining room where people were engaged in daily living tasks and staff were able to help people make drinks and snacks. People said their rooms were comfortable; one person had the door removed to their en suite to give them more room to move around in their wheelchair. All bedrooms were individual, with different decorations and furnishings; people were encouraged to bring their own pieces of furniture and personal possessions. On the third floor accommodation was being refurbished the lounge/dining/kitchen has been extended and redecorated. Also new beds with fixed bedrails had been purchased to ensure peoples safety. There is a full time handyman who carries out minor repairs and health and safety checks in the home. Staff were seen using disposable aprons and gloves appropriately and the staff said they had attended infection control training. Minutes of staff meetings also evidenced infection control and cleanliness were seen as a priority at Threshfield Court. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30. People who use this service experience good outcomes in this area. Trained and competent staff meet peoples’ needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People responded in the surveys that staff generally listens and act on what they say. Positive comments were made about the staff by people who live in the home and their relatives for instance: ‘Most staff are very patient, cheerful and kind. Training in moving and handling and use of hoists seems good.’ ‘As far as I have seen the carers are very experienced in looking after people with dementia and are always interacting with them.’ ‘Excellent very kind.’ The nurses spoken with during the site visit said there was one registered nurse and three care staff on Linton Unit and similar on Memory Lane. Staff said the numbers were normally sufficient unless someone was ill or on holiday. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 21 However, there was a mixed response from people living in the home and their relatives about whether there was always enough staff available in the home. Also, the off duty also evidenced on Linton unit the numbers of staff on duty were occasionally reduced to two care staff on a morning, and this appeared to be when other staff were on holidays. Staff spoken with confirmed they had attended training examples given were dementia care, protection of vulnerable adults, infection control, and back care etc. All felt updated and said the home provided them with enough training to carry out there work effectively. The deputy manager explained how staff had commenced a new induction programme, which was based on the foundation programme of Skills for Social Care. Also, a person living in the home described how staff were trained to look after their care needs by watching other care staff. The staff are also provided with a manual with up to date information. The pre assessment questionnaire states over half of the care staff have national vocational qualification level two or above in care. However, comments were made about how some of the staff were unable to understand people’s verbal requests fully. The manager needs to be confident that the nursing and care staff on duty have the appropriate communication skills to ensure people’s needs are met. Four staff records were looked at all contained the information necessary to protect people from harm such as full application forms, criminal record bureau checks, and written references. Also, where a person had come to work from abroad the necessary checks had been carried out from their country of origin. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 22 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): Standards 31,33, 35 and 38. People who use this service experience excellent outcomes in this area. Threshfield Court is run in the best interests of all the people who live there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The registered manager of the home is organised, competent and runs the home to meet the needs of the people who live there. The registered manager is an experienced nurse who had worked at the home for many years and has completed her management qualifications. During the site visit she was observed speaking to people in a friendly and warm manner, people appeared comfortable to approach her. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 23 A deputy manager supports her in her role and the two have worked together as a team for ten years. The deputy manager is in charge of training. All the staff spoken with said they felt well supported by the managers. The managers have been proactive in the area of dementia care and this has raised the profile of Threshfield. This helps provide staff with a broader insight providing up to date practice and improving the care people receive. The organisation has a good IT system, which supports the manager’s roles and responsibilities. The home is part of the Barchester group and follows their quality assurance programme and the staff carry out regular internal audits. The area manager carries out regular visits where they speak to people in the home about the service they receive. There are six monthly meetings and satisfaction surveys for people who live in the home so they can make their views known. The home obtained its Investors in People Award, which was reviewed in January 2007 and has won an award for innovation in dementia care in October 2006. The registered manager confirmed the home no longer holds any money for any of the people living in the home. People are invoiced for any extra costs on a monthly basis. The records were generally well maintained however the manager would benefit from making sure they were all kept in a way, which promotes confidentiality and data protection. The staff have regular health and safety meetings where staff discuss any health and safety issues and review procedures. At a meeting in February, the minutes showed bedrails were being reviewed, and an outside company was to carry out a health and safety audit. The registered manager and pre assessment questionnaire confirmed all the health and safety records are kept up to date. Staff confirmed they had undertaken training in regards to moving and handling and health and safety and fire safety. Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 24 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 4 STAFFING Standard No Score 27 2 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 X Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations The administration of all medicines must be accurately administered and recorded. This means medication must be given as it is prescribed and only signed for by staff if it has been taken by people. The manager should review the way it keeps some of the records to make sure they follow data protection guidelines. 1 OP37 Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Threshfield Court DS0000069346.V348265.R01.S.doc Version 5.2 Page 27 - 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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