Inspection on 23/02/06 for Town Thorns

This inspection was carried out on 23rd February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Town Thorns 15/08/07

Town Thorns 22/01/07

Town Thorns 16/09/05

Town Thorns 15/03/05

Town Thorns 09/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Town Thorns Brinklow Road Easenhall Rugby Warwickshire CV23 0JE Lead Inspector Lesley Beadsworth Unannounced Inspection 23rd February 2006 14:45 X10029.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 Town Thorns DS0000004324.V285078.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 and Care Homes for Adults 18 – 65*. 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. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Town Thorns Address Brinklow Road Easenhall Rugby Warwickshire CV23 0JE 01788 833311 01788 833379 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) BEN - Motor & Allied Trades Benevolent Fund Ms Helen Mary Owen Care Home 70 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (46), of places Physical disability (15) Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users accommodated into room 121 must be in the category of old age, not falling within any other category. 16th September 2005 Date of last inspection Brief Description of the Service: Town Thorns is a purpose-built care home and stands in more than 20 acres of grounds. It is designed as a continuing care centre to provide full nursing, residential care and sheltered housing accommodation to people who are connected with the motor and allied trade. The home is divided into four units: Nursing Care, Dementia Care, Residential Care and Younger Adults with Physical Disabilities Units. Town Thorns is situated near the village of Brinklow close to Rugby. The home has facilities for service users to engage in social activities within the home and in the community. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a part of a day from 14:45 to 17:45. The Clinical Nurse Manager was present for most of the inspection in the absence of the registered manager who was on a rest day. The Clinical Nurse Manager and the other members of staff present, cooperated fully with the inspection process. The home had recently experienced an outbreak of gastro-intestinal problems and although this had previously subsided a further case had been identified on the day of the inspection. The home was also recovering from the sad death of one of their staff a few days before. The home had therefore been under some pressure and a decision was made to base the inspection and this report on interviews made with the Clinical Nurse Manager, the administrative staff, the maintenance manager and one of the home’s physiotherapists; the areas viewed outside of the units; discussion with visitors at the home and examination of records and other documents. Visitors were also spoken with. What the service does well: Despite the current difficulties experienced by the home the staff met at this inspection were welcoming and cooperative. The home is allocated in more than 20 acres of attractive landscaped grounds and offers comfortable, attractive and safe surroundings. The areas of the home visited were clean, well decorated and without any offensive odour. Bedrooms are decorated at a minimum of when they are vacated and four were being decorated at the time of the inspection. Visitors are made welcome and are able to visit their friend or relative in private. Visitors spoken with spoke highly of the service provided. Health and safety has a high profile and all relevant checks, maintenance and servicing is in good order. The health and safety and welfare of residents are protected by good procedures and practices. The home has good procedures and practices to safeguard the financial interests of people living at the home. The home forwards notifications about incidents in the home required to meet regulation 37 promptly to the Commission. The organisation also forwards Regulation 26 reports as is required every month thereby monitoring the services provided at Town Thorns. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 6 The staff at the home have the knowledge required to be able to identify and protect residents from abuse. What has improved since the last inspection? What they could do better: The following were identified as areas that could be improved – There is a need for care plans to continue to improve in order to ensure that all areas of residents’ needs are met. The home needs to demonstrate that the three monthly weight timescale is adequate and reasonable and that other ways of monitoring weight loss are used between weighings. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 7 The organisation needs to continue to make alternative arrangements to meet the needs of the tenants in the sheltered accommodation. The registered persons must ensure that personal allowance, or other money belonging to a resident, is only given to another person, including relatives, with the permission of that resident. The following is also recommended – Money held for residents should be kept in individual packets or containers for each person with individual records, in order to maintain their dignity and autonomy. The organisation should consider updating the IT equipment in the home. For purposes of inspection and monitoring the information regarding hot water temperatures should be kept in one place and easily accessible. 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. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were inspected from this section on this occasion. EVIDENCE: Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 Some progress has been made in the home ensuring that there are suitable and consistent care plans on all four units. Medication procedures and practices safeguard residents. EVIDENCE: The Clinical Nurse Manager now audits care plans and personal risk assessments every three months, using a newly devised audit tool, to ensure that they are complete, consistent, contain the required risk assessments and are being reviewed and updated at a minimum of monthly intervals. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 11 A new care plan format has been devised within the organisation and there are plans for this to be implemented in the home. This format should ensure that all necessary areas of need and appropriate risk assessments are included in care plans. No current care plans were viewed on this occasion. Following the previous inspection a requirement was made that residents are weighed monthly. However the Clinical Nurse Manager advised that a decision had been made for this to apply only to any resident at risk and other residents would be weighed three monthly. The home needs to demonstrate that the three monthly weight timescale is adequate and reasonable and that other ways of monitoring weight loss are used between weighings. At the previous inspection it became apparent that tenants in the integral sheltered housing unit were using staffing resources from the residential unit of Town Thorns to meet their care needs. This is not appropriate as it takes care time away from the people living on the residential unit. The organisation was required to address this and has made a decision to register as a domiciliary agency to enable sheltered housing residents needs to be met by staff employed by this agency. An application for registration with the Commission has been requested. The home now ensures that any covert administration of medication is included in the individuals care plan following assessment and appropriate consultation thereby safeguarding the resident. Other areas of concern regarding medication at the previous inspection have been addressed by the home including, a new policy and procedure being produced; all medication is now correctly labelled; the medication trolley on the unit identified at the previous inspection is now taken into the dining room rather than being left unattended when administration of medication takes place; photographs are being added to Medication Administration Record Sheets in order to safely identify residents when administering medication. These photographs have been completed on two of the four units; handwashing facilities are available at all locations where medication is dealt with. Controlled drugs that are to be disposed of are currently kept in appropriate secure storage the new arrangements for their disposal can be implemented. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15 Visitors are made welcome and are able to visit their friend or relative in private. The organisation is providing new kitchen facilities for the Dementia Care Unit. EVIDENCE: Family members visiting a resident were spoken with at the inspection and confirmed that they were made welcome and that they could meet with their relative in private. They added that they were very happy with the services at Town Thorns. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 13 At the previous inspection it was noted that the kitchenette on one unit was in a poor condition. The Clinical Nurse Manager and Maintenance Person were able to confirm that a new kitchen was to be fitted on the Dementia Care unit before the end of March and that units had already been purchased. The provision of this will add to the comfort of residents and in controlling infection on the unit. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The staff at the home have the knowledge required to be able to identify and protect residents against abuse. EVIDENCE: Up to a third of the staff have now undertaken Adult Protection training to enable them to be able to identify the different types of abuse and thereby protect people living at the home from abuse. All staff in the home have received literature of this subject and eventually all will undertake the relevant training. The policy and procedures for Adult Protection have been updated by the organisation in line with the requirements of the last inspection and these were made available at the inspection. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 The areas of the home that were viewed offered attractive, comfortable and odour free surroundings. Residents have a lockable space in their private accommodation to enable them to safeguard their valuables. EVIDENCE: The areas of the home visited were clean, well decorated and without any offensive odour. The gardens/grounds cover an area of twenty acres and are well maintained and attractive. Based on the areas viewed, and a previous visit Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 16 to the home, the people living at the home have pleasant and comfortable indoor and outside surroundings. Information was given that four bedrooms were being decorated, all bedrooms being redecorated when vacated. The home has a team of maintenance personnel that is responsible for all maintenance, driving, decorating and gardening and for the checking of health and safety such as fire alarm testing and water temperature monitoring. The outcome is that the home offers well cared for and safe surroundings. The Clinical Nurse Manager advised that most residents have a secure and lockable space in their private accommodation in which they are able to keep money and valuables if they wish. They are offered a key to this facility. Some residents have chosen to have their own furniture rather than furniture belonging to the home and therefore may not necessarily have a lockable space. The Clinical Nurse Manager said that this facility will be offered or reason for it not being provided added to the care plan. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 The staff vacancies are satisfactorily covered by the use of agency staff. Staff have undertaken training appropriate to their specialist needs of the people on the unit on which they work. EVIDENCE: The home has several staff vacancies, one due to the tragic death of a member of the night staff. Agency staff cover these at the moment but the home is also presently recruiting for staff, including from overseas. The Clinical Nurse Manager advised that in the meantime the home was able to maintain some continuity of care to the people living at the home by the same agency staff working at the home and them being allocated to the same unit wherever possible. In addition to nursing, care, administrative, domestic and catering staff the home also employ a Maintenance Team consisting of a manager, and Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 18 designated staff responsible for on-going painting and decorating, gardening, general maintenance and the driving of the home’s vehicles. All staff working on the Dementia Care Unit have undertaken dementia training and one member of staff has also attended an Age Concern training course related to therapeutic activities for people with dementia. Staff on the unit for younger adults have undertaken, or will be undertaking training relate to learning disabilities. This training gives staff the knowledge and skills they require to meet the specialist needs of residents in Town Thorns. Other training undertaken by nursing and care staff includes Continence Management, Death, Dying and Bereavement, and specific nursing practice training. Other training is planned for the near future. A training coordinator has been appointed by the organisation to streamline the training of staff in all their homes and to maintain training development for employees, which should further assist staff to have the knowledge and skills that they require to meet the needs of the residents. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35, 37, 38 The home has good procedures and practices to safeguard the financial interests of people living at the home. The health and safety and welfare of residents are protected by good procedures and practices. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 20 EVIDENCE: Residents are encouraged to look after their own finances, to enable independence to be maintained. Some monies are looked after by the home for safekeeping and transactions for this money was inspected. Two members of staff, for reasons of security and protection, carry out all transactions. Money is banked on behalf of the residents in one non-interest account and transactions are maintained in one balance sheet. Cash held in the home for residents is kept together in one container and records maintained in a cashbook. To maintain the dignity and autonomy of individual residents the registered persons should consider transactions being individualised and each resident having there own designated packet/container for cash belonging to them. This should also assist in the administration and monitoring of monies and be easier to locate the source of any error. Personal allowance of a resident that is initially forwarded to the home is given directly to the daughter on his behalf. The home needs to ensure that there is evidence on record that this is the resident’s wish thereby safeguarding his financial interests. All policies and procedures of the organisation have been updated. The home is in the process of ensuring that they are individualised to meet the needs of Town Thorns. The home has a fax machine in the reception office and the nursing station to assist in administrative tasks. However it was noted that some Information Technology equipment used by staff is not up to date and that not all computers have access to a printer. The administrative staff were also experiencing problems with the organisation’s programme at the time. This may have an impact on the efficiency of staff when needing to use this equipment and ultimately on the service offered to the people living at the home. Fire prevention documentation was inspected and was in good order ensuring the safety of those working and living in the home in the event of a fire. A fire risk assessment had been updated in June 2005; fire extinguishers serviced in January 2006;fire hydrant check carried out October 2005; fire alarm maintenance was done in February 2006; emergency lighting is checked monthly and fire alarm had been checked each week and at a different call site to ensure that all points are checked throughout the year. As there are 58 fire alarm points throughout the premises the maintenance manager ensures that a different area is tested each week to minimise the risk of any area of the premises being without a functioning alarm point. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 21 All records related to health and safety were inspected and seen to be up to date. Hot water testing was being carried out as required and temperatures maintained at close to 43°C to prevent accidental scalding. However the recent testing had been recorded on database and was not readily available for inspection. It is recommended that a print out of this be kept with the other records. Risk assessments for working practices were in place to ensure that hazards are identified and appropriate action taken to protect the residents and staff. Accidents are recorded on each unit and the information forwarded to the administrative staff for accident analysis. It was suggested that each unit receive the information they require at more regular intervals than presently to enable them to monitor any trends in accident occurrence and to action appropriately. There was discussion about the duplication of accident recording and administrative staff advised of what is required by the Commission. The completion and returning of regulation 37 reports regarding incidents that have occurred in the home have been forwarded to the Commission. Up to date guidelines were given that should mean less of these reports needing to be written. Town Thorns DS0000004324.V285078.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 X 2 X 3 X 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 ENVIRONMENT Standard No Score 19 X 20 X 21 X 22 X 23 X 24 3 25 X 26 3 STAFFING Standard No Score 27 3 28 X 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 X 34 X 35 3 36 X 37 3 38 3 Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 23 Yes 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 15 S 3(1)(b) Requirement The registered manager must ensure that there are suitable care plans available for all assessed needs of the residents and that there is consistency in recording these in all four units. (The previous timescale of 30/11/05 was not met.) Timescale for action 30/04/06 2. OP8 14 17 S. 3(3)(m) 3. OP8OP27 18, 13, 14, 15 30/04/06 The registered manager must ensure that all residents are weighed at least monthly, records must be maintained clearly stating weight gain or loss and evidence that care plans have been devised. (The previous timescale of 30/11/05 was not met.) The home needs to demonstrate the reasons for any decision to weigh a person less frequently and what other measures are to be taken to monitor for any weight change. The registered manager must 30/04/06 continue to make domiciliary care services arrangements to meet the needs of the tenants in the sheltered accommodation. (The previous timescale of DS0000004324.V285078.R01.S.doc Version 5.1 Page 24 Town Thorns 30/11/05 was not met.) 4. OP15 13 The registered manager must ensure that the kitchenettes are in good condition. The Dementia Care Unit area requires a new work surface, new flooring and new fridge. (The previous timescale of 30/11/05 was not met.) All care staff must undertake Adult Protection training. The home must evidence that money belonging to a resident is only given to a person designated by that resident. 30/04/06 5. 6. OP18 OP35 12 1317 S.3 12(3)(4) 30/04/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP35 OP37 OP38 Good Practice Recommendations The registered persons should consider keeping individual persons money in separate packets/containers and transactions kept individually. The organisation should consider improving the standard of the IT equipment used by staff. Information regarding the temperatures of hot water should be kept in one place and be accessible for inspection. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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. Town Thorns DS0000004324.V285078.R01.S.doc Version 5.1 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. 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