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Inspection on 26/11/08 for Throckley Nursing & Residential Home

Also see our care home review for Throckley Nursing & Residential Home for more information

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff personnel records contain the required information to make sure residents remain safe. The home is clean, homely and comfortable. Residents` bedrooms were well personalised.A good variety of activities are available for residents to be involved in if they wish. Residents we spoke to said they were happy with the food. We tasted the food. There was homemade soup, a choice of risotto or stew and rhubarb crumble and custard. The food tasted good. It was hot enough and well presented. We spoke to some residents who told us they had come to the home for a look around before they were admitted. Their records showed that staff had assessed their needs before admission to make sure they could be cared for. Residents looked clean, they told us that they were happy with the care given to them. Most of the care plans detailing residents` care needs were up to date. Residents` medicines were well managed. Medication was properly stored, administered and disposed of. The manager checks the medications system regularly. Residents and relatives are consulted through a series of meetings. Residents told us that they would talk to a nurse or the manager if they had any problems or complaints.

What has improved since the last inspection?

Staff have received training in person centred care. This encourages them to see routines and practice from a residents` point of view. The attitude of most of the staff was good. They were polite and friendly to residents and offered them choices and options.

What the care home could do better:

The passenger lift was not working properly on the day of the inspection. It had been faulty for sometime and was awaiting a `part` to be fitted. The lift was sticking at the second floor. This was causing frustration to staff and a delay in moving residents around the home. During the lunch period there were several delays when staff tried to take residents to and from the dining room. We asked for this to be addressed immediately. We noted that there were still some institutional routines in the home. We observed that not all staff considered the resident when they were expressing their frustration at the faulty lift and walked away without explanation. This showed that not all staff have adopted the principles of person centred care.There are not sufficient assisted bathing facilities within the home. The top and lower ground floors have only unassisted baths. The two showers in the home have a tray that makes access difficult for physically disabled people. We did not think the home was well staffed. There is only one member of staff on the top floor. She was observed to ring the other floors several times for someone to relieve her in order for her to bath a resident. The staff were too busy to do this and the bath did not get done. The deputy manager was in charge of the home on the day and was also the nurse for a floor. There was no administrative help, therefore she was very busy trying to do both roles. Some furniture in the home was looking worn. These were mostly bedside tables and occasional tables in the middle lounge. Some toilets did not have handrails fitted, these are needed to keep residents safe. Most care plans were good. We looked at five, three were good, one showed a discrepancy between the assessment and plan of care and the final one had not been regularly reviewed. None of the staff had received training in infection control and water in staff hand washing sinks was too hot.

CARE HOMES FOR OLDER PEOPLE Throckley Nursing & Residential Home Ponteland Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9EP Lead Inspector Janet Thompson Key Unannounced Inspection 26th November 2008 10:00 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 Throckley Nursing & Residential Home DS0000040481.V373309.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. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Throckley Nursing & Residential Home Address Ponteland Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9EP 0191 267 5655 0191 229 1119 throckleygrange@highfield-care.com www.southerncrosshealthcare.co.uk Southern Cross Home Properties Limited 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) Mrs Elizabeth Ann Brennan Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP, maximum number of places: 48 The maximum number of service users who can be accommodated is: 48 10th July 2008 2. Date of last inspection Brief Description of the Service: The home is purpose built and located in the centre of Throckley. It is close to all local amenities and is on a local bus route. The home caters for up to 50 older people and has a maximum of 35 nursing care beds. There are spacious communal areas, dining rooms and a separate smoking lounge. A passenger lift services all areas. The home has 44 single bedrooms, some with en-suite facilities. Externally there are accessible gardens, patio areas and car parking is available. The home has access to a shared mini bus for outings. Fees vary and more information is available from the home. The home provides information about the service through the service user guide and statement of purpose. A copy of the last inspection report from The Commission for Social Care Inspection is available in the entrance to the home. Throckley Nursing & Residential Home DS0000040481.V373309.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. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations. This will only happen when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Before the visit: We looked at: • Information we have received since the last visit to the home. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service. The Visit: An unannounced visit was made on 26 November 2008. During the visit we: • Talked with people who use the service, relatives, staff, the manager & visitors. • Looked at information about the people who use the service & how well their needs are met, • Looked at other records which must be kept, • Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, • Looked around the building/parts of the building to make sure it was clean, safe & comfortable. We told the deputy manager what we found. What the service does well: Staff personnel records contain the required information to make sure residents remain safe. The home is clean, homely and comfortable. Residents’ bedrooms were well personalised. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 6 A good variety of activities are available for residents to be involved in if they wish. Residents we spoke to said they were happy with the food. We tasted the food. There was homemade soup, a choice of risotto or stew and rhubarb crumble and custard. The food tasted good. It was hot enough and well presented. We spoke to some residents who told us they had come to the home for a look around before they were admitted. Their records showed that staff had assessed their needs before admission to make sure they could be cared for. Residents looked clean, they told us that they were happy with the care given to them. Most of the care plans detailing residents’ care needs were up to date. Residents’ medicines were well managed. Medication was properly stored, administered and disposed of. The manager checks the medications system regularly. Residents and relatives are consulted through a series of meetings. Residents told us that they would talk to a nurse or the manager if they had any problems or complaints. What has improved since the last inspection? What they could do better: The passenger lift was not working properly on the day of the inspection. It had been faulty for sometime and was awaiting a ‘part’ to be fitted. The lift was sticking at the second floor. This was causing frustration to staff and a delay in moving residents around the home. During the lunch period there were several delays when staff tried to take residents to and from the dining room. We asked for this to be addressed immediately. We noted that there were still some institutional routines in the home. We observed that not all staff considered the resident when they were expressing their frustration at the faulty lift and walked away without explanation. This showed that not all staff have adopted the principles of person centred care. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 7 There are not sufficient assisted bathing facilities within the home. The top and lower ground floors have only unassisted baths. The two showers in the home have a tray that makes access difficult for physically disabled people. We did not think the home was well staffed. There is only one member of staff on the top floor. She was observed to ring the other floors several times for someone to relieve her in order for her to bath a resident. The staff were too busy to do this and the bath did not get done. The deputy manager was in charge of the home on the day and was also the nurse for a floor. There was no administrative help, therefore she was very busy trying to do both roles. Some furniture in the home was looking worn. These were mostly bedside tables and occasional tables in the middle lounge. Some toilets did not have handrails fitted, these are needed to keep residents safe. Most care plans were good. We looked at five, three were good, one showed a discrepancy between the assessment and plan of care and the final one had not been regularly reviewed. None of the staff had received training in infection control and water in staff hand washing sinks was too hot. 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. Throckley Nursing & Residential Home DS0000040481.V373309.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 Throckley Nursing & Residential Home DS0000040481.V373309.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 and 5, standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are fully assessed before they enter the home. EVIDENCE: There has been no change to the admission procedure since the last inspection. Care records showed that residents’ care needs are assessed before admission. This information was sufficient for staff to judge if they could meet the needs of each resident. One resident told us that she could remember coming into the home for a look around. She said that her medical history was taken. Another resident said that her daughter looked at the home for her as she was in hospital at the time. An up to date statement of purpose and service user guide is available in the home. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 10 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. Residents receive personal care that is well planned but not always reviewed. All staff do not always treat residents respectfully. EVIDENCE: Five care plans were examined and two were case tracked. This means that we spoke to the individual residents or observed their care then matched our observations to what was written in the care plan. Both case tracked care plans did reflect the actual care needed by the residents. However one resident’s risk assessment for tissue viability showed her as low risk when in practice she was very high risk. The deputy manager said she would check this assessment again. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 11 One of the case tracked care plans had not been regularly evaluated. The skin integrity and hygiene plans had not been evaluated since July. Other evaluations had not been done in October or September. This resident’s plan said she was a diet controlled diabetic, blood sugars were recorded. Some of the readings appeared high, there were no parameters set in the care plan and no evidence of any action to address this. There were notes in the professionals’ record that showed she was referred to the diabetic clinic by the chiropodist with a diabetic ulcer and commenced on medication for her diabetes. There was no mention of an ulcer in her care plan. This care plan had not been evaluated since August. A care plan written recently for a chest infection was unreadable due to the handwriting. Three care plans were well written and had been regularly updated. Residents looked clean and well cared for. Those spoken to said they were well looked after. Residents told us that they could see a Doctor if they were unwell. One resident told us she had recently been to hospital and staff had supported her when she felt confused by the procedures and worried at the outcome. Medication ordering, administration, storage and disposal were examined. The manager audits all medicines monthly and the operations manager also carries out an audit. Medicines were all recorded and administered correctly. One amount of controlled drug was checked and was correct. Staff have received training in person centred care. Most of the practice observed was good. Staff were polite to residents and protected their privacy when carrying out personal care tasks. Some staff did not appear to have taken on the principles of person centred care. They appeared busy and harassed, they referred to “doing the toilet run” before lunch. These staff were particularly affected by the malfunction of the lift. We observed that they left residents in wheelchairs in front of the lift doors without explanation on two occasions. One of the residents was continuing a conversation with the carer she thought was still behind her. This does not yet demonstrate respect for the individual person. The deputy manager also witnessed the same practice and said she would speak to the staff individually. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 12 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. People are supported to lead a healthy and fulfilling personal lifestyle. This takes account of their wishes and diverse abilities. EVIDENCE: An activities coordinator is employed in the home three days per week. A reasonable range of activities is available. Residents’ social needs are assessed and were recorded in their care plans. Residents told us that they could join in with the activities if they like. One resident said she doesn’t always want to join in and can choose not to. Residents told us that they can have visitors at any reasonable time. One resident said his family visit regularly and have got to know the staff. Another resident told us that her relative comes in and has coffee with her. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 13 Residents were offered choices on a number of occasions. All residents spoken to said that they enjoy the food. We ate the food, which was homemade soup, risotto followed by rhubarb crumble and custard. It was tasty, hot enough and well presented. Residents are also offered a cooked tea. We observed that residents were assisted to eat by staff when needed. Residents appeared to enjoy their meal and there was a good atmosphere in the dining room. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 14 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. People who use the service are protected from harm through thorough policies, procedures and staff training but complaints were not fully recorded. EVIDENCE: Staff follow the home’s policies and procedures relating to the management of complaints and allegations of abuse. Staff are kept up to date with information and training. All staff have received training on the protection of vulnerable adults. There has been one issue requiring the intervention of the safeguarding adults team. CSCI has been made aware of this. Residents are told how to complain through the complaints procedure. This was clearly visible within the home. Residents spoken to said they would complain if they needed to but none of them had any current complaints. There have been three complaints since the last key inspection. CSCI has been involved in one of these. Most have been resolved to the satisfaction of the complainants. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 15 The ‘relatives communication’ record in a resident’s care plan showed that her relative had complained that she had not had her bed sheets changed since admission, she wanted a new mattress and a new carpet had been promised. The carpet was promised in September, we checked the residents’ room and she told us the carpet had not arrived. There was no evidence that this was followed up and it was not in the complaint record. Throckley Nursing & Residential Home DS0000040481.V373309.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, 21, 23, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe comfortable home that is generally pleasant and clean but not fully hygienic. The bathing facilities do not meet residents’ needs. EVIDENCE: The home was generally clean and free from odours. The furniture and general décor provides residents with a comfortable homely environment. Residents told us that the staff work hard to keep the home clean. They said that they liked their bedrooms and that they were warm enough. One resident said bits of the home were a bit shabby but on the whole it was good enough. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 17 Residents’ bedrooms were attractive and well personalised. A number of residents had brought items from home. One resident told us that she had brought some bits of furniture from home and it helped her to feel more settled. We noticed that the occasional tables in some lounges looked worn, as did many of the bed tables. The lift was not working on the day of inspection and had been intermittently broken for some time. The lift was sticking on one floor. We asked for immediate action to be taken, we were told that a ‘part’ was on order for the lift. The lift was fixed shortly after the inspection. There were some toilets that did not have a guardrail fitted for residents to use for balance. The bathing facilities in the home are mostly unassisted. Residents have to step in the shower trays or climb in the bath. Most of the residents cannot do this. The residents have to be taken to another floor to use the baths. This causes problems because when staff have to leave one floor they have to find someone else to relieve them. Records show that the water in some staff hand washing sinks is as hot as 5052°C. This means that good hand washing techniques cannot be followed, as staff cannot wash their hands under running water. None of the staff have had training in infection control. Some of the bins in the home do not have lids that are operated by foot. This is essential to limit contamination and the spread of infection. Several of the bedroom carpets on the lower ground floor were stained. These carpets looked quite old. There were no unsecured hazardous substances. There were no obvious trip hazards. Throckley Nursing & Residential Home DS0000040481.V373309.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. People using the service are supported and protected through staff skill and ability. Staff numbers are not sufficient to meet residents’ needs. EVIDENCE: At the last key inspection the staffing was: Two qualified nurses 8am to 9pm One qualified nurse from 9pm to 8am Seven carers from 8am to 2pm Five carers from 2pm to 4pm. Six may be on duty if dependency levels in the home are high. Six carers from 4pm to 9pm Four or five carers from 9pm to 8am. At this inspection the staffing of carers had dropped to six carers in the morning, five in the evening and four at night. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 19 We did not think the home was well staffed. There is only one member of staff on the top floor. She was observed to ring the other floors several times for someone to relieve her in order for her to bath a resident. The staff were too busy to do this and the bath did not get done. This staff member also had to wait a long time to take a break. Staff appeared rushed and in a hurry to carry out tasks. This does not support or encourage them to take a person centred approach. Training records showed and staff confirmed that 75 of staff had achieved NVQ level 2. Apart from infection control essential training was up to date. All staff had received training in Moving and Handling, Protection of Vulnerable Adults, Fire and Hazardous Substances. Four staff recruitment files were examined. These were for one new carer, one nurse and two long term employed carers. All contained good information. Thorough background checks had been carried out before employment. Residents were protected through checking of criminal records information for all employees. Throckley Nursing & Residential Home DS0000040481.V373309.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, 32, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using this service are not protected through reflective management that takes account of the diverse needs of the service. EVIDENCE: The home does have a registered manager. The manager has been assessed by CSCI as ‘fit’ to run the home. The manager is experienced in nursing and management. The manager was on leave at the time of the inspection. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 21 The deputy manager was in charge of the home on the day of inspection and was also the nurse for a floor. There is no administrator in the home at the present time. The deputy manager was therefore very busy trying to do all roles, answering the telephone, dealing with visiting health professionals, running the home, supervising staff and being the nurse for her floor. She did manage well but was clearly very busy. We have discussed this with the provider who has agreed to provide better management support to the home or more supernumerary hours for the deputy in the absence of the manager. The manager conducts a series of audits in the home. These include auditing of systems, records and care practice. Residents and relatives are consulted about the running of the home through meetings. The last meetings were held in September. Staff also attend meetings at which new information is shared. Minutes of these were examined. Staff are reminded that the home should be run in the best interests of residents. Previous sections of this report have shown that this is not yet always happening in practice. Servicing and maintenance agreements are in place for facilities and equipment. These were up to date apart from the electrical installation certificate. This was issued in 2000. These are valid for five years. It is therefore out of date. This compromises the safety of the building and all in it. Remaining checks for gas, hoists, lifts and water chlorination were up to date. There were no obvious trip hazards in the home. Fire exits were clear of obstruction and all hazardous fluids locked away. Residents’ personal monies could not be checked. These are held as computerised accounts. There is currently no administrator and the deputy manager does not have access to the system. If residents require money they are given it from petty cash with double-signed signatures obtained for all transactions. This is not an ideal system as the deputy was unable to inform residents or their relatives as to their current balance. We have discussed this with the provider, who has agreed to look at how to provide better support. Throckley Nursing & Residential Home DS0000040481.V373309.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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 X 3 3 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 2 X X 2 Throckley Nursing & Residential Home DS0000040481.V373309.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. 2. Standard OP7 OP16 Regulation 15 22 18 Requirement Care plans must be regularly evaluated. They must reflect he actual care needs of the person. Provide staff with training in the recognition of complaints. Provide CSCI with confirmation that the elements of the complaint in question have been acted upon and recorded. Review the bathing facilities. Residents must have access to suitably adapted baths and showers. Conduct a review of infection control practice to take account of the comments in this section. Train staff in infection control. Records relating to residents money must be open, transparent and available for inspection. Provide the Commission with evidence that essential safety checks for the building have been carried out. Ensure that these continue to be kept up to date. DS0000040481.V373309.R01.S.doc Timescale for action 01/01/09 01/02/09 3. OP21 23 01/03/09 4. OP26 13(3) 16 01/02/09 5. OP35 17 01/01/09 6. OP38 13(4) 01/01/09 Throckley Nursing & Residential Home 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. 4. 5. Refer to Standard OP10 OP19 OP27 OP32 OP33 Good Practice Recommendations Takes steps to ensure that all staff treat residents with respect at all times. Conduct a review of the premises to ensure all carpets and furniture is of an acceptable standard. Conduct a review of staffing. Give consideration to providing two carers on every floor and three to floors with higher occupancy/dependency. Provide better management support in the absence of the manager. Demonstrate the improvements made to ensure the home is run in the best interests of residents. Throckley Nursing & Residential Home DS0000040481.V373309.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Throckley Nursing & Residential Home DS0000040481.V373309.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!