Inspection on 25/04/06 for Thurnscoe Hall Nursing Home

This inspection was carried out on 25th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Thurnscoe Hall Nursing Home 16/11/07

Thurnscoe Hall Nursing Home 03/04/07

Thurnscoe Hall Nursing Home 09/11/05

Thurnscoe Hall Nursing Home 03/05/05

Thurnscoe Hall Nursing Home 12/10/04

Thurnscoe Hall Nursing Home 04/06/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Thurnscoe Hall Nursing Home High Street Thurnscoe Rotherham South Yorkshire S63 0ST Lead Inspector Mrs Jayne White Key Unannounced Inspection 25th April 2006 09:45 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 Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 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. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thurnscoe Hall Nursing Home Address High Street Thurnscoe Rotherham South Yorkshire S63 0ST 01709 890086 01709 894363 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) www.thurnscoehall.co.uk Mr Rajendra Prasad Vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 55 years and above Of the 26 beds, 12 are nursing care (N) and 14 are personal care (PC) Date of last inspection 9th November 2005 Brief Description of the Service: Thurnscoe Hall is a 17th Century stone built Grade 2 listed building with a purpose built extension and conservatory. The home is registered for 26 residents aged 55 years and above. Twelve of the registered places can be used for residents requiring nursing care. The home stands in its own extensive gardens with mature trees and shrubs and has a sitting area for residents and their families. Accommodation is on three floors, served by a passenger lift. There are 22 single rooms and two double rooms. There is a car park to the side of the building. It is situated in Thurnscoe village ten miles from Barnsley town centre, close to the A635 Barnsley to Doncaster road, with easy access by bus or train. The home is within walking distance of all local amenities, including, supermarkets, chemist, optician, post office, hairdressers, community centre, bowling green, pubs, clubs, the village church and health centre. On 25 April 2006 the fees for the home ranged from £315.00 to £415.00. The National Health Service nursing care contribution is in addition to these fees and ranges from £40.00 to £133.00 dependant on the level of National Health Service assessed need. The administrator provided this information in writing. The home had a service user guide that provided some information about their service for current and prospective residents. A CSCI report about the service was also available to current and prospective residents in the entrance of the home but it was not the report from the last inspection on 9 November 2005. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced site visit carried out between the hours of 9:45 and 16:15 by two inspectors, Jayne White and Cathy Howarth. The home had provided some information to assist with the site visit. Opportunity on the visit was taken to make a partial inspection of the premises, inspect a sample of records, observe staff carrying out their duties and talk to residents, relatives, staff and the manager. Also taken into account was other information about the service since the last inspection and comments about the service from seven of the twelve questionnaires returned from residents and relatives. The majority of residents and staff were seen during the inspection and the inspectors spoke in more detail to two members of staff on duty about their knowledge, skills and experiences of working at the home, four residents about their views on aspects of living at the home and one relative. The inspectors wish to thank the residents and staff for their time and co-operation throughout the inspection process. What the service does well: Discussions with residents and relatives identified the home was run in the best interests of residents. Residents were able to make choices about daily routines and discussions with residents and relatives described how on the whole the lifestyle they experienced within the home met their expectations and preferences and satisfied their social, religious and recreational interests and needs. Residents said they received a good standard of care; comments included “All the carers are kind – you have ones you prefer but all are kind and treat you with respect and dignity” and “I’m happy here – it’s not much to look at but it’s the care that matters”. Assessments of need to enable a plan of care to be prepared for residents were in place and staff adhered to the home’s policies and procedures for dealing with medicines. Residents maintained contact with family and friends and members of the local community as they wished. Good relationships between staff and residents were evident. The majority of care staff were trained to at least NVQ level 2 in care and other training opportunities were available for staff. Staff were observed approaching residents in a respectful manner and respecting individual preferences. In the main, residents were happy with the food provided. Residents and relatives could be confident their complaints and any allegations of abuse would be listened to and acted upon. The home was clean and one resident’s comment about this was “our home is always fresh and clean”. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 6 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. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 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 Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcome for standard three was inspected. Standard 6 was not All residents moving into the home had, had his/her needs assessed. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The assessment of need for two residents were requested and in place. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 7, 8, 9 & 10 were inspected. All resident’s health, personal and social care needs were set out in an individual plan of care, but omissions and lack of detail were evident. Resident’s health care needs appeared to be fully met, but improved recording in the individual plan of care was needed to demonstrate this. Residents were protected by the home’s policies and procedures for dealing with medicines. Residents’ rights to privacy was on the whole maintained, however, there were areas that could be improved. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 10 EVIDENCE: Residents spoken with spoke positively about their personal care needs being met. The seven questionnaires returned identified residents always or usually received the care and medical support they required. Two individual care plans were inspected on a sample basis. The plan contained relevant information on the care required to meet the resident’s health and personal care needs but omissions and lack of detail were evident. For example, nutritional screening did not demonstrate clear monitoring of weight gain/loss and any actions taken. More information was required on how social care needs are to be met and family contacts. A record of falls was maintained but no falls risk assessment was in place with a clear management plan and actions to be taken where necessary with appropriate interventions. There was also no risk assessment for residents that self-harm. There were no residents with pressure sores and staff were proud of their interventions to prevent these. The recording, administration and storage of medication were inspected on a sample basis. Records were kept of medication being received into and leaving the home and appropriate arrangements had been made for the disposal of the medication of residents receiving nursing care. Medication administration records were fully completed. Qualified nursing staff administered medication and medication, including controlled drugs, were stored appropriately and securely, maintaining the heath safety and welfare of residents. Residents spoken with said that they were well cared for, staff treat them with respect and they were able to spend time in their room if they wish. Staff were observed approaching residents in a respectful manner and respecting individual preferences. Good relationships between staff and residents were evident. One resident commented “All the carers are kind – you have ones you prefer but all are kind and treat you with respect and dignity”. All toilet and bathroom areas inspected did not have a working lock, which may compromise the privacy and dignity of the residents. A notice was present on one resident’s door to remind staff to maintain infection control protocols. This should not be necessary and could compromise the resident’s right to confidentiality. To use the telephone the resident’s had to use the office telephone, as one was not available for use specifically by residents. This meant staff were aware when residents chose to make telephone calls, which did not respect their privacy for their own actions. Continence protectors were placed on some chairs in the lounge and hoist slings were also left in place beneath residents who had moving and handling needs. These practices do not promote the dignity of those residents and leaving the hoist sling beneath residents can be a health and safety risk. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 12, 13, 14 & 15 were inspected. Discussions with residents and relatives described how on the whole the lifestyle they experienced within the home met their expectations and preferences and satisfied their social, religious and recreational interests and needs. Residents maintained contact with family and friends and members of the local community as they wished. Residents on the whole were assisted to exercise choice and control over their lives. Residents received a varied diet in a pleasant dining area, although a more positive choice would add to the meal on offer. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 12 EVIDENCE: Seven questionnaires were returned. There was a varied response as to whether residents’ social care needs were met as one identified the home always arranged activities they could take part in, three said they never did, one said they usually did and one said sometimes they did. Individual care plans did not identify residents’ social care needs so clarity of what these might be could not be determined. Residents’ spoken with described how they could choose to spend their day and confirmed that they could choose what time to get up and go to bed within reason, accepting the constraints as part of group living. The majority of residents were observed to spend time in the lounges with interaction between themselves and/or the staff, whilst others had chosen to spend their time in the privacy of their bedroom spending time as they wished. One resident and relative said a programme of activities have been tried and they have observed that most residents are not interested. The relative said birthdays are celebrated and staff do fund raising to buy personal gifts at Christmas and Easter. Residents confirmed that they maintained links with their family and friends and that they could visit “at anytime”. Relatives confirmed this and the fact they were always offered a drink. Personal items and furniture were brought into the home by residents to personalise their rooms. As one resident commented “having your own possessions makes it feel more like home because it’s not home”. Of the seven questionnaires returned residents identified the meals were always or usually good. Discussions with residents and relatives were in the main positive about the food; residents stated that they were given the choice of a cooked breakfast everyday and residents spoken with said that they had enjoyed lunch. The menus displayed were not appropriate for residents to see what the meals were for that day and although the menu was varied it did not provide a choice, this being offered if the cook was aware of anything the resident disliked. The lunchtime meal was observed with plenty of attention being provided by staff. Staff ate with the residents, monitoring and assisting where necessary. The presentation of the dining area would be enhanced if the tablemats where the plastic coating was bubbling were replaced. Residents stated that they usually had assorted sandwiches and cakes for tea but that soup and a hot snack was also offered at teatime and they could have a sandwich, bun or biscuits for supper. However some staff felt that the residents would benefit from improved menus at teatime. The manager stated that the catering team had been awarded a silver award for catering by the local authority. The training matrix identified there were staff who had undertaken the intermediate food hygiene training and other staff had received food handling training. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 16 and 18 were inspected. Residents and relatives could be confident their complaints would be listened to and acted upon. Staff had a reasonable understanding of the procedures to be followed should they suspect any abuse at the home, however, there may be inappropriate action as the local multi agency procedures from all relevant authorities were not in place. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 14 EVIDENCE: Of the seven questionnaires returned all knew how to complain and five knew who to speak to if they weren’t happy. There was a record of complaints. Where a previous complaint made to the CSCI had been unresolved in regard to residents receiving timely assistance when requested and not left in rooms unassisted for any length of time, this was inspected as part of the site visit. It was noted residents received timely assistance when requested and were offered drinks and snacks in their room if they spent any length of time there. Likewise a new tumble drier had been purchased where a complaint had been upheld in regard to late return of laundry because of a broken tumble drier. A copy of the Barnsley and Rotherham multi agency adult protection policies and procedures were available to staff and staff had received adult protection training. A resident funded by another local authority was living at the home; the adult protection policy and procedure for this local authority had not been obtained, but the manager was aware she needed to obtain this from the last inspection and was waiting for the resident’s review to approach the social worker. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 19 & 26 were inspected. The living environment was clean but improvements were still required to ensure it was well maintained and safe for residents. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 16 EVIDENCE: Residents stated that they were happy and their bedrooms were comfortable and that they had everything they needed. Feedback from the seven resident questionnaires identified four thought the home was always fresh and clean, one usually and one sometimes. One comment included “our home is always fresh and clean”. Another resident commented “I’m happy here – it’s the care that matters. I know it’s not much to look at”. Refurbishments and redecoration in the past twelve months have included some repairs to the roof in the conservatory, repair of a damaged wall, replacing of tiles and some guttering, re-plastering of the ceiling on the second floor and new lounge chairs, improving the living environment and comfort of residents. The plastic covering on the handrail on the stairs was still detached from the handrail and one bedroom ceiling was still awaiting a new tile where it had sustained some damage from a leaking pipe. This room was unoccupied. The toilet and bathroom areas had bar soap in evidence, which poses risk with the spread of infection. The kitchen area had cupboard areas with no doors or doors that were hanging off. The fly screen did not cover the doors and windows sufficiently to prevent flies from entering the kitchen area. These concerns were referred to the environmental health department. There was clutter in a number of areas which detracted from the living environment including three sets of bed rails and a shower chair that was rusting in a bathroom area, free standing hairdryer in the conservatory. Outside there was a broken light fitting in the car park, rubbish, a pile of bricks, old fridge, a broken fence and a light that needed repairing above the main entrance. This detracted from the otherwise tidy gardens with mature trees and shrubs. Laundry facilities were sited on the lower ground floor/cellar away from food preparation and storage areas. Hand washing facilities were provided. There were gaps in the laundry flooring and therefore was not in a good enough condition to ensure all steps had been taken to control the spread of infection. This was referred to the environmental health department. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 27, 28, 29 & 30 were inspected. Resident’s needs were not sufficiently met by the numbers and skill mix of staff. Residents were in safe hands. Residents were protected by the home’s recruitment policy and practices. Staff were trained and competent to do their jobs. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 18 EVIDENCE: Some residents felt that there was enough staff to meet the needs of the current number of residents, whilst other residents thought that more staff would enable staff to spend more time with residents. Residents stated that their needs were met and staff always responded in a timely manner with assistance if they used the call alarm system. This wasn’t always the case if they were in lounges, as attachments were not in the call alarm system and residents were unable to reach them anyway. If there were any delays the residents accepted this as part of a group living environment. Observation of staff responding to assistance as required was good. The manager described the staffing arrangements as a nurse was on duty on each shift to assist with the nursing needs of the seven residents requiring nursing care. In addition to this there were two care assistants on the morning shift and one on the afternoon and night shift. The staff rota confirmed this. However, the staffing notice agreed by the home in November 2000 states two care staff must be on the afternoon shift. Observation of staffing on the afternoon identified assistance for and supervision of residents may be of concern at that time due to the needs of residents, the layout of the building, with a number of residents in their own rooms and staff also carrying out kitchen duties. The staff rota did not include the surnames of care and kitchen staff and domestics and laundry staff were not on the rota although the manager did state there were two domestics Monday to Friday and a laundry assistant daily. This was observed. Ninety nine per cent of care staff held NVQ level 2 in Care. Staff stated they had opportunity for training and in 2006 had received training including fire, moving and handling, health and nutrition. This was recorded in their personal training record and certificates to demonstrate qualifications and training of staff were also in place. Staff were observed approaching residents in a respectful manner and respecting individual preferences. Good relationships between staff and residents were evident. Residents stated that they were satisfied with the level of care they received and that staff knew how to care for them. Two staff files were inspected on a sample basis. A recruitment procedure for one staff member was demonstrated including receipt of two satisfactory references, a statement by the person as to his mental and physical health and a criminal record check, however, satisfactory written explanation of gaps in employment were not documented. For the other staff member a thorough recruitment procedure could not be confirmed as although they are employed by the home, their file is held by another registered service in the same building that the inspector did not have access to. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 31, 33, 34, 35, 37 & 38 were inspected. Although the manager has been working at the home for some time she is not registered with the CSCI. Discussions with residents and relatives identified the home was run in the best interests of residents, however, there was no formal quality monitoring process. Records did not demonstrate residents’ financial interests were fully safeguarded. On the whole, the home’s record keeping policies and procedures safeguarded residents’ best interests. On the whole, the health, safety, and welfare of residents and staff were protected, but some improvements are needed to improve their protection. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The manager is a nurse with management experience, however she is not currently registered with the Commission for Social Care Inspection. This has been brought to the owner’s attention on three occasions since April 2005. The manager gave the inspector the application at the site visit. The inspector explained the process for registration had now been amended and there would be further information to be submitted before the application would be valid. This was confirmed and another application forwarded to the manager. There was no formal quality assurance process that sought the views of residents and other stakeholders of the service but some residents stated that the manager spends time talking to them about the home. Although the owner visits the home frequently reports of his visits as required by the regulations were not sent to the CSCI. They were given to the inspector during the site visit with the manager stating she had been waiting for Mr Prasad to sign them. Further discussions identified they were not being completed by Mr Prasad. This did not demonstrate a proactive involvement to improve the quality of the service provided by the owner. It must be noted, however, that residents’ and their advocates on the whole expressed satisfaction with the service. Relative and resident feedback forms were available in the foyer to enable feedback to be given. A valid insurance certificate was submitted prior to the site visit. Residents were encouraged to maintain control over their own finances unless they did not want to or lacked capacity. Staff were aware of the procedures for handling residents money, written records were kept of all transactions, which included two signatures and receipting systems. However, there was no clear record of personal allowances paid to residents whose finances were dealt with by the home. One resident’s monies was checked and reconciled with the record. There were safe facilities to store the monies. Bank accounts were held in resident’s names. When the building was inspected no fire exits were blocked and the fire extinguishers seen had been serviced. There were weekly checks of the emergency lighting and fire alarm. A sample of staff fire training and drills were inspected and found to be satisfactory. Information provided to the CSCI identified servicing of the gas installations, central heating system, fire equipment, portable electrical appliances, hoists and call systems together with confirmation that appropriate repairs/replacements had been completed where necessary. There was no confirmation that the fixed wiring was satisfactory. There were appropriate measures in place to ensure the security of the premises and prevent intruders. Window restraints had been fitted to windows to prevent falls. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 21 Notifiable incidents were being reported to the CSCI. The water temperature record identified water temperatures were checked on a sample weekly basis. One water outlet inspected was close to forty-three degrees centigrade, which is identified as a safe temperature for residents. Information provided to the CSCI identified written assessments of control of substances hazardous to health had been completed and a contract was in place for the disposal of soiled waste and sharps. When inspected the laundry and cleaning cupboard which were located on the lower ground floor down a set of steps were vacated and not locked, which could pose a risk to residents due to falls and/or having access to hazardous substances being insecurely stored. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 2 X 2 2 Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard OP7 OP12 OP7 OP7 OP8 Regulation 15 & 17 15 & 17 15 & 17 Requirement The care plan must detail how the social care needs of residents are to be met. The care plan must contain appropriate contact details for family, GPs, care manager etc. The care plan must contain a nutritional risk assessment with identified intervention and action to be taken by staff as appropriate. The care plan must contain a falls risk assessment with identified intervention and action to be taken by staff as appropriate. The care plan must contain risk assessments for self harm where necessary with identified interaction and action to be taken by staff as appropriate. All toilet and bathroom areas must have locks that work. All local multi agency adult protection procedures must be in place at the home. The handrail on the staircase must be repaired. Previous timescale of 09.02.06 DS0000006492.V290930.R01.S.doc Timescale for action 30/06/06 30/06/06 30/06/06 4. OP7 OP8 15 & 17 30/06/06 5. OP7 OP8 15 & 17 30/06/06 6. 7. 8. OP10 OP18 OP19 12 & 23 13 23 30/06/06 30/06/06 31/08/06 Thurnscoe Hall Nursing Home Version 5.1 Page 24 9. OP19 23 10. OP19 23 11. OP19 23 12. 13. OP27 OP29 18 19 14. OP29 19 15. OP31 9 not met. The ceiling on the second floor must be redecorated. Previous timescale of 09.01.06 not met. The ceiling in the identified bedroom, must be repaired. Previous timescale of 09.01.06 not met. All areas of the environment must be kept tidy, free from hazards and safe for residents use. Two members of care staff must be on the afternoon shift. A thorough recruitment process must be demonstrated for all staff employed by the care home. The recruitment process must demonstrate a full employment history, together with written explanation of any gaps in employment. The manager of the home must be registered. Previous timescale of 04.01.05 & 09.03.06 not met. A written report of the owner’s monthly visit must be completed and forwarded to the Commission for Social Care Inspection (CSCI). Previous timescale of 09.12.05 not met. The financial record must include an audit trail of the payment of personal allowances. Records as required by the regulations must be in place (these have been identified throughout the report). The home must demonstrate servicing of fixed wiring. The laundry door and cleaning DS0000006492.V290930.R01.S.doc 31/08/06 31/08/06 31/08/06 31/08/06 30/06/06 30/06/06 30/06/06 16. OP33 26 30/06/06 17. 18. OP35 OP37 17 17 30/06/06 30/06/06 19. 20. OP38 OP38 13 13 30/06/06 30/06/06 Page 25 Thurnscoe Hall Nursing Home Version 5.1 cupboards must be locked when a member of staff is not in the vicinity. 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. 6. 7. Refer to Standard OP10 OP10 OP10 OP10 OP15 OP15 OP15 Good Practice Recommendations A telephone specifically for the use of residents should be provided. Notices to remind staff to use infection control procedures should not be placed on residents’ doors. Continence protectors should not be placed on residents’ chairs. Hoist slings should not be left beneath residents when sitting in lounge chairs. The meal on offer should provide choice for residents. The menu for the day should be displayed in an appropriate format for residents. Tablemats should be replaced. Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 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 Thurnscoe Hall Nursing Home DS0000006492.V290930.R01.S.doc Version 5.1 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. 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. 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