Inspection on 07/11/06 for Thurlston House

This inspection was carried out on 7th November 2006.

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

Thurlston House 10/11/05

Thurlston House 25/05/05

Thurlston House 16/11/04

Thurlston House 02/06/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Thurlston House Victoria Hill Road Fleet Hants GU51 4LD Lead Inspector Tracey Box Unannounced Inspection 7th November 2006 09:30 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 Thurlston House DS0000034233.V300531.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. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thurlston House Address Victoria Hill Road Fleet Hants GU51 4LD 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) 01252 628520 Hampshire County Council Position vacant Care Home 49 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (49) of places Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2005 Brief Description of the Service: Thurlston House is a large residential care home, managed by Hampshire County Council, which was first officially opened on 26 March 1974. The home is over two floors with all the bedrooms on the ground and first floor. There is a large garden. Thurlston House is situated within a mile of Fleet town centre. Thurlston House is able to offer care for up to forty-nine older persons, in the category OP and up to fifteen service users in the category, DE[E], for those suffering from dementia. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The people living at Thurlston house prefer to be referred to as residents, therefore the rest of this report will reflect this. The opportunity was taken to look around the home, view records, procedures and talk with residents and staff. The inspector also had the opportunity to observe the interaction between residents and staff. Two residents were spoken with who stated that they were happy at the home. The staff on duty during this visit felt they were supported to do their job. Two relatives said they were very happy with the care and support their relative receives, they are made to feel very welcome at the home. The manager confirmed the fees for the home are £390.00 per week. What the service does well: What has improved since the last inspection? Three requirements made at the last inspection have been actioned. Care plans include the findings of a mental status questionnaire which has been completed with each resident, and is reviewed every 3 months to track trends. Two new baths have been installed. The majority of staff have attended a four day dementia awareness training course, this is an ongoing programme for the home. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 6 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. Thurlston House DS0000034233.V300531.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 Thurlston House DS0000034233.V300531.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): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information they need to make an informed choice with regards to moving into the home. The home does not provide intermediate care. EVIDENCE: The inspector looked at the most recent pre admission assessment records, which included a hospital and social workers assessment, the manager visited the prospective resident to complete the home’s pre admission assessment, the resident’s family were involved providing information also. The pre admission assessment includes a moving and handling, clinical and functional assessment. The manager confirmed she is appropriately qualified to complete these assessments. One resident recalled the manager visiting them, and asking a lot of questions like ‘what I liked and disliked, my interests, family history’. The manager confirmed the home do not provide intermediate care. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 9 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 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans do not fully reflect the individual’s health, personal & social needs, to ensure their personal needs are met. The home ensures residents healthcare needs are fully met. Residents are protected by the homes medication policies & procedures. Residents feel they are treated with dignity and respect & that they are given information to enable choice. EVIDENCE: Since the last inspection individual’s Care plans include the findings of a mental status questionnaire that is reviewed every 3 months to track trends. However further work is required to ensure care plans include up to date information and clear guidelines in supporting residents who become agitated. Some care plans included inappropriate words, therefore further training is required to enable staff to record and report more effectively. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 10 Staff said ‘We know the residents and how they like to be cared for, the care plans give us the guidelines we need to support the resident’. The inspector looked at five care plans and risk assessments, (three of which were for residents who had been admitted since the last inspection) records showed that they had been reviewed, however the changes identified during the review had not been documented in the part of the care plan specific to the change of need. One care plan did not state that a resident was receiving pressure area treatment. The inspector asked the manager where about in the care plan any changes to a residents behavior are documented, as a review of a residents care plan identified this as a change, again this was not recorded in the main care plan. The manager said she would look into this as it was important all the relevant and current information is included in the care plans and risk assessments. Comprehensive records showed that residents received visits from GPs and other health professionals such as district nurses, CPN, opticians and dentists as required. A resident said that her chosen GP visited her when she was unwell recently and this was seen documented in her daily records. Staff requested a care manager visit a resident as they had identified a change in her needs, the care manager visited on the day of the inspection, and was happy with the care and support the resident was receiving. During the inspection staff telephoned the Community psychiatric nurse and a GP to visit a resident who was unwell. One relative said ‘I cannot fault the care my father has received during his stay here, if the staff have the slightest concern about his health, they call the appropriate person, and let me know as well which is very important to me.’ Staff were seen to be pro active at obtaining healthcare professionals support, one resident obtained a pressure sore, records showed staff responded quickly by requesting a district nurse visit. During the inspection staff swiftly answered an emergency alarm which resulted in staff administering first aid and calling an ambulance, this was done in a calm, professional and orderly way, staff said they were clear of their responsibilities and roles in a situation like this. The manager confirmed that policies and procedures are reviewed and available for staff to access regarding residents’ health and personal care, and that residents access healthcare professionals when required. The inspector witnessed medication being administered in accordance with the homes policies and procedures by one member of staff who said has completed medication administration training. Medication records seen had been completed appropriately. Records for controlled drugs were signed by two staff members and the number of tablets remaining were documented, the number of tablets, which were stored appropriately, matched the records. At the time of the inspection there were no residents who were administering their own medication. One resident said that she preferred the carers to look after her tablets, as ‘I don’t want to worry about them’. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 11 Currently the home does not hold any ‘homely’ remedies and there was no medication that required storage in the fridge. Staff induction records showed that privacy and dignity and the provision of personal care are covered during the induction process, and the response from residents indicated that the carers treat them with dignity and respect and that they are trustworthy. One resident told the inspector that staff respected their choice and privacy at all times. The inspector witnessed staff talking to service users in a respectful manner. Staff said they are aware of the importance of dignity and respect, one staff said, “ I treat people as I wish to be treated”. Thurlston House DS0000034233.V300531.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise control over their lives, participate in social activities, receive visits from friends and relatives as they wish and enjoy a choice of meals served in a relaxed atmosphere. EVIDENCE: Residents spoken with said that they were able to exercise choice over their daily living activities and participate in a variety of things, which include quizzes, musical movement, board games such as draughts and connect 4, watching videos of old films and musicals. One unit manager arranges activities on a monthly basis, these include volunteer singers, keep fit, church services and trips out to various places of interest. On the day of the inspection the afternoons entertainment was provided by two care staff, and involved music making with various instruments. The manager confirmed that policies and procedures are in place to ensure residents are supported to lead active lives as they prefer, however care plans did not fully reflected this. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 13 The registered manager said that there were no residents from an ethnic minority at present but that if a resident had cultural or religious interests every effort is made to accommodate this. Records showed residents attending Holy Communion (offered twice a week) and a church service held at the home once a month. The home has an open visiting policy. This was evidenced by records of visitors to the home and confirmed by relatives and one relative said they visit the home at different times of the day and are always welcomed, she also said she has received tremendous support from all staff during her relatives stay. The inspectors observed residents eating lunch in the dining room, the atmosphere was relaxed, residents were offered choices of main meal and desserts, residents were asked if they wanted more to eat after their meals. Staff gently prompted residents to encourage eating. Cold drinks, tea and coffee with biscuits were available throughout the day and staff are able to access the kitchen at night to provide hot drinks and snacks for residents who wish them. The fridge was well stocked with fresh produce, all foods were covered and dated. Thurlston House DS0000034233.V300531.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure, which residents feel able to use and an adult protection procedure to safeguard residents from abuse EVIDENCE: The home had a complaint’s policy in place that indicated who would investigate any complaint and timescales for the process. A log to record complaints was also available, however it did not include whether the complainant is informed of any action the home will take, or if the complainant was satisfied with the action taken. The manager said letters are sent to explain action that will be taken, however as the inspector saw, this is not recorded. The manager amended the complaints record immediately to include this information, which will refer the reader to the place where any written correspondence is held. The inspector recommended the pages of the log be numbered sequentially to allow the reader a true record of complaints received, again the manager actioned this immediately. A resident said that if anything caused concern she would ‘chat to the staff or the manager and something would be done about it’. Residents spoken with were aware of whom to complain to, should they have a need to, although at present they were happy with the care they receive. One relative said they have never had to complain, only complement. Should they need to, they would talk to staff. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 15 Four staff members spoken with said that they are aware of the correct procedures to follow if a disclosure of abuse was reported to them, however they had not received any formal training in abuse awareness, therefore a recommendation was made for all staff to attend training. The home has procedures for staff to follow should abuse be suspected, including Hampshire County Council’s Protection of Vulnerable Adults and Whistle Blowing. The manager confirmed that policies and procedures are reviewed and available for staff to access regarding complaints and protection, staff confirmed this. The home have investigated a disclosure of abuse appropriately, following policies and procedures and involving the appropriate authorities, records were seen of this, and that the informant was informed of the outcome of the investigation. Thurlston House DS0000034233.V300531.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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment provides residents with a warm and comfortable home. Residents would benefit from two baths being replaced, and all bathroom door locks replaced to prevent residents from being locked in. There is a good infection control procedure at the home to safeguard the welfare of residents. EVIDENCE: The home was warm and welcoming, all parts of the home seen were well maintained and tastefully decorated. There was ample communal space, the home has one large lounge, two smaller lounges and a large dining room. The home looked clean and homely and resident’s bedrooms looked comfortable and contained many personal items such as pictures and ornaments. Two residents spoke of their satisfaction with their rooms with comments of ‘it’s comfy’ and ‘I have everything I need’. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 17 Keys are provided for residents who wish to lock their doors. One resident commented about the “lovely” garden and the views from their rooms and communal areas. The garden was accessible to residents and was well maintained. Since the last inspection two new adapted baths have been replaced, one resident said ‘I really enjoy my baths, and now it is much easier for staff to get me in and out’. The inspector saw two bathrooms which appeared shabby and did not provide a pleasant environment for residents to enjoy bathing, therefore a requirement was made to replace these baths, the manager said she thought this work has been planned as part of the homes annual maintenance plan. All of the bathroom doors were locked to safeguard residents, however the locks were broken. Staff said they cannot access the bathrooms in a hurry, as it takes some time, and a certain ‘nack’ to open them, therefore the inspector requires all bathroom door locks are replaced to prevent residents from being locked in and to enable staff easy access in case of an emergency. The home has an internal laundry that is well equipped, however there was no provision for an escape route in the event of an emergency, therefore a requirement was made under Regulation 23 within this report. Infection control procedures were in place. Staff were observed to follow this guidance, equipment such as gloves and aprons were available. Staff said they had received infection control training, however not all certificates were in place to support this. Thurlston House DS0000034233.V300531.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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of staff appear to be appropriately trained, however records do not show this. There is sufficient skill mix within the team and to meet the residents needs. The recruitment procedure for the home must be improved to ensure the vulnerable people living in the home are protected. EVIDENCE: The home has adequate staff numbers and skill mix to meet the residents needs, the majority of staff have been working in the care sector for most of their careers and know the residents well. The home has a duty rota that reflects this. Staff said the residents needs have changed over the last couple of years, but staffing levels have not been increased, the home is currently using existing and agency staff to cover annual leave, sickness and vacancies, however the home have recently completed a successful recruitment campaign which resulted in staff being interviewed for two full time care assistant, domestic and laundry positions. It was evident from practices and interactions observed that staff had developed good relationship between themselves and residents. Comment from residents included that staff were very kind and always helpful and that they were a “good team”. One resident praised the domestic staff for their hard work in keeping their bedrooms clean and tidy. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 19 The inspector started to examine copies of three staff recruitment records. One was found to be in order, there was evidence that written references had been obtained, an application form had been completed and evidence of personal identification was available. It was evident that two staff who had transferred from another Hampshire County Council owned home in August 2006 had not applied for a position at Thurlston house, references related to their applications which were obtained for their positions at the other home, their CRB’s related to the other home and their previous job role. The inspector examined staff files from other staff who had transferred from the other home, five were insufficient. The manager confirmed work is underway to obtaining CRB’s for all the staff who have transferred, as not all staff could find their copies of their CRB checks to update this homes staff files. The inspector requested staff who have not yet applied for a CRB, and therefore do not have a Protection Of Vulnerable Adults (POVA) check, do not work alone and do not under any circumstances carry out personal care. An assistant unit manager assured the inspector that this only applied to one member of staff who would not be working on their own, and that she would ensure the member of staff was aware of the importance of this. Therefore a requirement was made that all staff obtain a CRB check appropriate to their role and employer. Staff confirmed they are working towards their induction and foundation standards in line with skills for care guidelines. The managers explained at present the majority of its workforce either working towards, or have achieved National Vocational Qualification (NVQ) levels 2 and 3. The inspector sampled records of the fire drill log, which showed unannounced fire drills occur regularly, all records of fire alarm and equipment were satisfactory. The manager explained staff have received adequate training, and three staff said they had received appropriate training to enable them to carry out their role correctly, However not all certificates were available to show that staff have attended mandatory training in health & safety, moving & handling, first aid, fire safety and infection control. The home employ three staff to cook, two were on duty during the inspection, One cook said she has attended training in malnutrition, diabetes and food hygiene, certificates confirmed this. The certificates in the other two cook’s files were not current, one record showed the cook had not received any training at all since commencing her post in August 2006 (previously she worked at another Hampshire County Council owned home.) The other file showed basic food hygiene training was completed in 2000, therefore was out of date, the manager said the staff member had attended food hygiene awareness in April 2005, however there was no certificate to confirm this. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 20 The manager said the staff probably have their certificates at home, the manager was informed a requirement would be made to ensure certificates of training completed by staff are held in the home. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is managed well and run with their best interests in mind. The home’s procedure for dealing with the majority of residents’ finances is good and safeguard resident’s interests. The procedures and practices for the health and safety of residents is good, however some procedures and practices for staff need to be improved. EVIDENCE: The Manager is not yet registered with the Commission for Social Care Inspection, the provider will provide written confirmation to the CSCI as to the management arrangements for the home. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 22 The staff said there are clear lines of accountability, with staff feeling confident in the managers abilities and they feel supported by their line manager. The home has an internal audit system in place that seeks the views of residents, relatives and other healthcare professionals on a regular basis. The most recent survey was sent out in October ’06, no responses had been returned for the inspector to see. The manager said she collates the data and produces a report which is available for residents, relatives and any others who responded. The provider undertakes monthly reviews of the environment. Residents and staff views are sought and reports of these are available to the Commission, either when an inspector visits or they would be sent to the Commission if requested. Residents have the opportunity to air their views at residents meeting which are held regularly and are minuted. Twenty residents handle their own financial affairs, the home stores their money and corresponding records safely. The inspector looked at three records and they were found to be correct records of the money held. The manager completes ‘spot checks’ for all resident’s money, records showed this was last completed in June ’06. The manager confirmed residents can access their money at any time. The manager said relatives send money to the resident as and when they need it, the home safeguard the money until it is needed. One resident said ‘if I need any money I get it, I sign to say how much I have received, and another member of staff confirms this amount.’ The staff confirmed they receive formal time with their line manager and can discuss and issues or concerns at any time. Staff said they feel supported by the manager. The manager and five assistant unit managers have line management responsibilities, all said they have received formal supervision training at some point in their career. The home has a policy, procedures and information on health and safety. A sample of policies and procedures was seen and it showed that these are reviewed regularly. All COSHH materials are maintained safely. There is an ongoing system in place that ensures that all appliances are serviced, records and certificates seen indicated that the systems such as the electrics and specialist equipment including bath aides received regular servicing and maintenance. The employer’s insurance liability certificate was displayed and current. Fire records available indicated that regular checks were made on fire safety equipment and staff had received training in fire safety. The fire drill records showed that all staff had attended a fire drill in the last year. Staff said that they would not be able to evacuate the laundry area if there was an emergency, due to the laundry door leading into a corridor, there is not a direct escape route to the outside of the home. The inspector spoke with the Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 23 manager about this, and she will discuss it with her line manager to see how it can be rectified quickly, a requirement was made. Thurlston House DS0000034233.V300531.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 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 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 3 17 X 18 2 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X x 2 Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 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 OP7 Regulation Schedule 3.(1,b) Requirement The provider must ensure care plans include relevant information and clear guidelines informing staff how to meet the individual resident’s needs. The provider must replace two baths to meet the residents’ needs. The provider must ensure documentary evidence of all relevant qualifications of each staff member is kept in the home. The provider must ensure there is evidence held in the home of staff receiving a satisfactory CRB check relevant to their job role and employer. The provider must ensure there are adequate means of escape from the laundry room. The provider must replace all bathroom locks to enable staff to gain easy access in an emergency and to prevent residents from being locked in. Timescale for action 20/12/06 2. 3. OP21 OP28 23(2,c, j) Schedule 2.(4). 20/12/06 20/12/06 4 OP29 Schedule 2.(7,a,b). 20/12/06 5. 6. OP38 OP38 23(4,b). 23(2,c). 20/12/06 20/12/06 Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP18 Good Practice Recommendations Staff would benefit from recording and reporting training to enable them to write care plans more effectively. Residents would be further protected from abuse if staff received training in adult protection issues. Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Thurlston House DS0000034233.V300531.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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