Care Home: Thackley Grange

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What the care home does well The home is well managed and people are consulted about how they want their care and support to be provided. The manager has an open door policy and encourages people to tell her what they think about the service. There are regular meetings arranged for people living at the home and there are recognised quality assurance monitoring systems in place. People have the opportunity to join in a range of social and leisure activities and are encouraged to make choices and decision about how they want to spend their time while living at the home.Thackley GrangeDS0000033578.V376739.R01.S.docVersion 5.2The home has established close working relationships with other health care professional to make sure people`s health care needs are met and they have access to the full range of NHS services. A thorough staff recruitment and selection procedure and a commitment to staff training makes sure that people that use the service are cared for and supported by staff that are suitable to work in the caring profession. Comments from people living at the home and/or their relatives included the following "the staff are kind, considerate and very friendly and I look forward to my short stay visits" and “I am very pleased with the care and support provided by the staff and now feel I made the right choice by moving in to the home.” What has improved since the last inspection? The home has built on the good practices noted during the last inspection visit and there is a genuine commitment by both management and staff to provide people with quality care. What the care home could do better: Staff must be more vigilant when managing controlled drugs so that people living at the home can be confident that their medication is being stored, administered, and disposed of appropriately. The manager needs to complete the registration process as soon as possible to evidence that she has skills and experience to manage a registered service. Key inspection report CARE HOMES FOR OLDER PEOPLE Thackley Grange Boothroyd Drive Town Lane Idle Bradford West Yorkshire BD10 8LN Lead Inspector Steve Marsh Key Unannounced Inspection 24th July 2009 09:00 DS0000033578.V376739.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thackley Grange Address Boothroyd Drive Town Lane Idle Bradford West Yorkshire BD10 8LN 01274 613937 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) City of Bradford Metropolitan District Council Department of Social Services Vacant Post Care Home 34 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (32) Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 2007 Brief Description of the Service: Thackley Grange is a Bradford Local Authority run purpose built property including a day care centre, it accommodates up to 34 older people with mental disorder including dementia on a permanent and short stay basis. The home is managed over two floors and is a short walk away from a range of shops including a post office, grocery store, cafés, and public houses. The home is easily accessed by public transport and the main bus routes for Shipley, Leeds, and Bradford pass close by. The home has a range of bathroom and toilet facilities for independent and assisted use There is a good-sized car park to the front and side of the building. The home has extensive gardens including an enclosed area. Information provided by the home in respect of fees shows that people pay according to their financial assessment. Currently fees range from £108:08 a week (low rate) to £173:60 (medium rate) and £435.68 (highest rate). The last inspection report is available in reception. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is three star (3*)excellent service. This means people that use the service experience excellent quality outcomes. The methods we used included looking at records, observing staff at work, talking to people living at the home and visitors, talking to staff and looking around the property. Before the visit we had provided some people living at the home, staff and other health care professionals with survey questionnaires so that they could share their views of the service with us. We received nine questionnaires back from people living at the home, seven from staff and two from healthcare professionals. The information they provided has been used as evidence in the body of the report. The home had also completed and returned their Annual Quality Assurance Assessment (AQAA) form and the information provided has also been used as evidence in the body of the report. The AQAA is a self assessment form that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. We have recently improved our practice when making requirements to improve national consistency. Some requirements from previous inspections may have been deleted or carried forward as recommendations, but only when it is considered that people that use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. No requirements or recommendations have been made as a result of this inspection. Feedback was given to the manager at the end of the visit. What the service does well: The home is well managed and people are consulted about how they want their care and support to be provided. The manager has an open door policy and encourages people to tell her what they think about the service. There are regular meetings arranged for people living at the home and there are recognised quality assurance monitoring systems in place. People have the opportunity to join in a range of social and leisure activities and are encouraged to make choices and decision about how they want to spend their time while living at the home. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 6 The home has established close working relationships with other health care professional to make sure peoples health care needs are met and they have access to the full range of NHS services. A thorough staff recruitment and selection procedure and a commitment to staff training makes sure that people that use the service are cared for and supported by staff that are suitable to work in the caring profession. Comments from people living at the home and/or their relatives included the following the staff are kind, considerate and very friendly and I look forward to my short stay visits and “I am very pleased with the care and support provided by the staff and now feel I made the right choice by moving in to the home.” What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Thackley Grange DS0000033578.V376739.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 Thackley Grange DS0000033578.V376739.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, & 5 – Standard 6 is not applicable to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admission process is thorough and people will not be admitted unless staff are able to meet their needs. People are provided with good information about the service and are encouraged to visit and see the facilities at first hand before deciding if the home is right for them. EVIDENCE: The information provided about the service is good and helps people decide if the home can meet their needs. At the current time the information is only available in English but the manager confirmed that it would be made available in different languages and formats on request. The home is also able to engage the services of an interpreter if needed. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 9 Records show that peoples needs are always assessed before they move into Thackley Grange either in their own home or temporary place of residence. Needs identified during this pre-admission assessment visit form the basis for the initial care plan, which is completed on admission. People are invited to visit the home before admission to see at first hand the facilities provided, meet the staff and other people living there and stay for a meal if they wish to do so. People are also able to move in to the home for a trial period if they are still undecided. This is good practice and shows that people are supported through the admission process. The home tries not to admit people on an emergency basis however if this is unavoidable a full assessment of their needs is completed on the day of admission. Feedback from people shows that they felt the information they received about the home before admission was very good and the initial visit was helpful and informative. People also told us that there is a good mix of skills within the staff team and staff had a good understanding of their needs. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care and support is delivered in a manner that respects peoples privacy and dignity. EVIDENCE: Care plans are in place for all people living at the home and are initially generated from the information provided by the Social Services Care Management Team or the assessment of needs completed by the manager. Care plans are drawn up with the involvement of the person using the service and/or their relatives and form the basis for the care to be provided. The four care plans we looked at were completed to a very good standard and were being reviewed at least monthly to make sure that they accurately reflected the level of care and support required by the individual. The Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 11 information provided was person centred and gave clear guidance to staff on how to meet peoples needs. Moving and handling and nutritional assessments are routinely carried out for all new admissions and risk assessments are also completed where areas of potential risk to peoples general health and welfare are identified, which is good practice. All people living at the home are registered with a general practitioner and are supported in having access to the full range of NHS services. The survey questionnaires returned by healthcare professionals show that they feel the home is meeting people’s health care needs and staff always seek advice if they have concerns. Their input is clearly recorded in the documentation completed at the home. The home also operates the key worker system, whereby everyone living at the home has a named member of care staff as their key worker who is responsible for providing them with information and support throughout their stay. People confirmed that they were happy with the care and support they received and said that staff always treated them with kindness and respect. Comments included staff understand my illness and make sure that I receive the care and support I need to lead a full and active life and It is important to me that I remain as independent as possible and staff support me in any way they can to achieve this. Feedback from relatives spoken with on the day of the visit shows that they are also pleased with the standard of care and facilities provided and were always kept informed of any significant changes in peoples general health. We reviewed the medication system in place and found that generally medicines are managed safely. However, when we checked the medication held in the controlled drugs cabinet on one unit against the register we found that medication recorded has having being returned to the chemist for disposal was actually still in the cabinet. Staff must therefore be more vigilant when managing controlled drugs so that people living at the home can be confident that their medication is being stored, administered, and disposed of appropriately. Thackley Grange DS0000033578.V376739.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are offered the opportunity to take part in a varied range of social and leisure activities that take account of their preferences and abilities. EVIDENCE: The manager confirmed that people are encouraged to make choices and decisions about how they spend their time whilst living at the home. Peoples personal interests are recorded in their care plan and wherever possible they are supported by staff to follow their own daily routines. The home has recently employed a part time activities co-coordinator who is responsible for arranging a range of social and leisure activities for people living at the home. For people that dont like to join in group activities, time is made to engage with them on a one-to one basis. The home is fortunate to have a mini bus available, which is used to provide people with trips out to places of interest. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 13 People told us that they were pleased with the level of activities. Comments included the home provides the opportunity for people to join in a range of activities if they wish to do so and “there is always something going on if you want to join in – we are very lucky. Information provided in the service user guide shows that daily newspapers and magazines can be delivered to the home on request and for people choosing to live at the home on a long stay basis, private telephones billed directly to the individual can be installed. A pay phone is also available. The manager confirmed that people are encouraged to continue to attend their place of worship if they wished to do so and the home has established good relationships with local churches. Information provided in the self-assessment form does however show that the home is aware that more could be done to develop better local community contacts and plans to do so within the next twelve months. People spoken with said that they were able to see visitors in their own rooms if they wished to do so and family and friends were always made to feel welcome and offered light refreshments when they visited. We observed the lunchtime meal being served, which looked appetising and was well presented. If people required assistance or prompting to eat their meals this was done in a discreet and sensitive manner so that they were not caused any embarrassment. People told us that the food is always good both in quality and presentation and they are always offered an alternative if they dont like what is on the menu. Comments included there is a good choice at mealtimes and the food is always well cooked and the food is first class. Following a kitchen inspection by the Environmental Health Department the home was awarded the maximum five star rating for food safety and hygiene. Thackley Grange DS0000033578.V376739.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable systems in place to make sure that complaints are dealt with appropriately and people are protected from abuse. EVIDENCE: There is a clear complaints procedure in place and information provided in the self assessment form shows that the home operates a zero tolerance approach when dealing with complaints and adult protection (safeguarding) issues. People living at the home said that they were aware of the complaints procedure and would have no problem at all in approaching the manager or registered provider if they had any concerns about the standard of care being provided. Information provided in the self assessment form shows that no complaints have been received from people living at the home, their relatives or other healthcare professionals in the last year. Adult protection policies and procedures are in place and training records provided by the manager show that all staff have received training in the recognition and reporting of allegations of abuse. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 15 Thackley Grange DS0000033578.V376739.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is maintained to a good standard, providing a warm and relaxed environment with good personal and communal space. EVIDENCE: Thackley Grange is a thirty-four bedded specialist Resource Centre providing long stay, short stay and respite care services for people with a history of mental health problems. The home is split in to two units with ten beds available on the ground floor for people staying on a short stay or respite care basis and twenty-four beds on the first floor for people living at the home on a long stay basis. There is a passenger lift available for easy access to the first floor. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 17 Bedrooms and communal areas including lounges and kitchens/dining rooms are situated on both units. All areas of the home are decorated and furnished to a satisfactory or good standard and there is an ongoing programme of refurbishment and renewal. The home provides all singles bedrooms but none have en-suite facilities. Communal bath/shower rooms and toilets are conveniently located throughout the building. It is apparent when talking with the manager and staff that they take a great deal of pride in providing people with good quality accommodation and keeping the home clean and tidy. People living at the home said that they were satisfied with the standard of accommodation and pleased that they had chosen to live or stay at Thackley Grange. Comments included the home has such a warm friendly atmosphere and the rooms are well decorated and furnished. On the day of the visit the home was clean and tidy and free from any offensive odours. Thackley Grange DS0000033578.V376739.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that live at the home are protected by the staff recruitment and selection procedures in place. The home provides staff with good training opportunities and makes sure that they are clear about their roles and responsibilities. EVIDENCE: The home has a thorough staff recruitment and selection procedure, which includes obtaining at least two written references and a Criminal Record Bureau (CRB) check before new staff start work. This makes sure that people that use the service are cared for and supported by staff that are suitable to work in the caring profession. We looked at four staff recruitment files and found that they were kept in good order and contained all the relevant information. The staff rota showed that sufficient care staff are employed on day and night duty to meet peoples needs. Sufficient domestic and catering staff are also employed to make sure the home is kept clean and people’s dietary needs are met. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 19 . All new staff receive induction training in line with the Skills for Care Common Induction Standards. These are nationally agreed induction standards designed to help new staff get the skills and knowledge they need to care for people. Following induction there is an expectation that staff will study for a National Vocational Qualification (NVQ) at level two or three above depending on the post they hold. The home also provides staff with the opportunity to attend training courses on a variety of topics relevant to their work they undertake and there is an annual training and development plan in place. This shows that the home is committed to making sure that people are cared for by a skilled and experienced staff team. Feedback from the staff spoken with confirmed that they are happy with the level and standard of training provided and are encouraged to take up training opportunities. Staff also felt that the training the receive helps them understand the individual needs of people living at the home and keeps them up to date with new ways of working. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management structure in place makes sure that the home is well managed and run in the best interest of the people living there. EVIDENCE: Ms Lynn Hindley is the manager of Thackley Grange and is currently going through the registration process although due to unforeseen circumstances this is taking longer that anticipated. Ms Hindley has many years experience in the caring profession and has achieved a recognised management qualification. Ms Hindley has a positive attitude to the inspection process and during the Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 21 course of the inspection showed a willingness to work with us to maintain and improve standards at the home. The manager is supported in her role by a deputy manager, an assistant manager and four senior care assistants who make up the management team. Feedback from staff and people living at the home shows that the manager is approachable and operates an open door policy, which means that they are able to speak to her at any time if they have any problems. Team meetings and full staff meetings are held on a regular basis to make sure there are clear lines of communication within the home and staff are kept up to date with changes in policies and procedures. Staff also confirmed that they have one-to-one supervision with the manager on a regular basis and the majority felt well supported by the senior management team. However, questionnaires returned by three staff clearly indicate that while they feel staff work well as a team, management did not always recognised the pressure they were under. Comments included “at times we need a bit more understanding from the management team and support when needed and “when we raise concerns with management they do not always act to resolve issues.” This matter was discussed with the manager who confirmed that she would put it on the agenda for the next senior staff meeting and would take steps to make sure that staff feel appreciated and valued. There is a range of quality assurance monitoring measures in place including sending out survey questionnaires to people using the service and their relatives. The questionnaires give people the opportunity to express their views of the service provided and are an important part of the quality assurance monitoring process. Information in the self-assessment form shows that people living at the home are also able to comment on how service is delivered at their monthly meetings and through informal discussions with the manager and staff. The home holds money in safekeeping for a number of people. Only senior staff deal with peoples personal finances and receipts are obtained for any items purchased on their behalf. We checked the system in place and no concerns were raised. People can therefore be confident that the system is safe and well managed. Information provided in the self-assessment form completed by the manager shows that policies and procedures are in place to make sure staff follow safe working practices and all equipment is serviced in line with manufacturers guidelines. People can therefore be sure that their health and safety is not being compromised. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 24 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 25 Thackley Grange DS0000033578.V376739.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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