Care Home: Thamesbrook

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What the care home does well Thamesbrook has an experienced and well trained staff team who provide a high standard of care to people in both the residential and nursing units. Staff at all levels have good access to training and are encouraged in their professional development. Feedback in the surveys and from the residents spoken with was very positive. Residents and relatives confirmed that they felt confident in the staff, ‘who look after people well’. One resident commented that he ‘couldn’t fault the care’ he had received. One relative noted that residents’ cultural needs are recognised, for example through being supported to attend places of worship and services such as the Caribbean Centre in North Kensington. The rehabilitation unit has been successful in helping a significant percentage of its users to return home or to less supported settings, as well as providing a source of expert advice and knowledge to other units. Staff work closely with health care colleagues to ensure that residents’ health care needs are met. Food is freshly prepared in the kitchens, with a choice available at each meal. Catering staff are involved in the units, finding out what residents like to eat and meeting special dietary needs. Residents’ nutritional needs are carefully monitored by staff and action taken where there are concerns.ThamesbrookDS0000033393.V378696.R01.S.docVersion 5.2 What has improved since the last inspection? There were no requirements from the last inspection. What the care home could do better: The absence of staff in key posts for a considerable period, in particular the Deputy Manager and Dementia Care Team Leader, has meant that some areas of the service, not directly concerning residents’ care, have received less monitoring and oversight. For example a number of documents, including the Service User’s Guide and complaints procedure need to be updated and made available to residents and their families. A greater consistency in assessment and care planning needs to be established, so that the high standards seen on Brompton are in place on all units. A placement review meeting must take place for all new residents six weeks after they move to the home. In one instance, while action was taken to protect a resident, the Borough’s safeguarding procedures were not followed, nor were events fully documented. Training for all staff in safeguarding policies and procedures is scheduled to start in January 2010, which should ensure that staff awareness of the actions they should take is improved. Residents’ files should include a daily record of care, including nursing care given. Key inspection report CARE HOMES FOR OLDER PEOPLE Thamesbrook Royal Borough of Kensington & Chelsea 2 Dovehouse Street Chelsea London SW3 6LA Lead Inspector Sheila Lycholit Key Unannounced Inspection 21st December 2009 10:50 DS0000033393.V378696.R01.S.do c Version 5.3 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. Thamesbrook DS0000033393.V378696.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 Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thamesbrook Address Royal Borough of Kensington & Chelsea 2 Dovehouse Street Chelsea London SW3 6LA 020 7352 1004 Telephone number Fax number Email address peter.donkin@rbkc.gov.uk Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Borough of Kensington & Chelsea Care Home 56 Category(ies) of Dementia (56), Old age, not falling within any registration, with number other category (56) of places Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 56 12th March 2007 Date of last inspection Brief Description of the Service: Thamesbrook is a care home with nursing located in a residential area just off the Kings Road in Chelsea. It is run by the Royal Borough of Kensington and Chelsea. The home provides accommodation for up to 56 older people in five units over three floors. Two of the units are for people with dementia who do not need nursing care. There are three units with nursing. In addition there is a 5 place rehabilitation unit. All bedrooms are single rooms, which are of a good size and have en suite shower rooms. Externally there are very well maintained and attractive gardens to the side and rear of the home and a sheltered first floor patio. Thamesbrook is close to two tube stations and to frequent bus routes on the Kings Road. Limited on-site parking is available. Thamesbrook DS0000033393.V378696.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 3 stars. This means that the people who use the service receive excellent outcomes. The unannounced visit took place on Monday 21st December 2009 from 10.50am until 5.10pm. The Manager was on duty, with the Acting Deputy Manager. There were 54 residents, one of whom was in hospital, and 2 vacant places. The Manager made herself available throughout the visit. The Head of Provider Services also called at the home to answer any queries. Time was spent on Sloane Square, one of the units for people with dementia and on Brompton which provides nursing and has the rehabilitation unit. Records and documents were looked at, including the annual quality assurance assessment (AQAA) completed by the Manager in September. Two residents on Brompton were spoken with in private and discussion took place with staff on both units. Seven questionnaires were received from residents and relatives in September and October. What the service does well: Thamesbrook has an experienced and well trained staff team who provide a high standard of care to people in both the residential and nursing units. Staff at all levels have good access to training and are encouraged in their professional development. Feedback in the surveys and from the residents spoken with was very positive. Residents and relatives confirmed that they felt confident in the staff, ‘who look after people well’. One resident commented that he ‘couldn’t fault the care’ he had received. One relative noted that residents’ cultural needs are recognised, for example through being supported to attend places of worship and services such as the Caribbean Centre in North Kensington. The rehabilitation unit has been successful in helping a significant percentage of its users to return home or to less supported settings, as well as providing a source of expert advice and knowledge to other units. Staff work closely with health care colleagues to ensure that residents’ health care needs are met. Food is freshly prepared in the kitchens, with a choice available at each meal. Catering staff are involved in the units, finding out what residents like to eat and meeting special dietary needs. Residents’ nutritional needs are carefully monitored by staff and action taken where there are concerns. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.2 Page 6 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. Thamesbrook DS0000033393.V378696.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 Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 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 and 6 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. Generally, assessments are of a high standard, reflecting the experience and specialist knowledge of staff. A well run rehab unit is successful in supporting its users to return home or to more independent accommodation. EVIDENCE: The Manager stated that the service user’s guide is available but is not up to date and is not routinely given to new and prospective residents and their families. She undertook to review the information provided at the earliest opportunity. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 9 The individual files of 5 residents were looked at, 3 on Broughton and 2 on Sloane Square. All but one of the files contained detailed assessment information, showing that staff from Thamesbrook had visited the resident on at least one occasion before their admission and had collated a range of information about their needs. Assessments seen on Broughton were of a particularly high standard, with comprehensive information about the person’s nursing and care needs, consideration of their need for psychological support and relevant information about their social and support network and cultural background. The individual file of the most recently admitted person on one of the dementia units contained information about her needs from her Social Services file, to which senior staff at Thamesbrook have access, but did not contain a record of pre-admission assessments made by staff on the unit. Further clarification could not be sought from the Acting Team Leader of this unit, as she was off sick. Thamesbrook has a 5 place rehab unit on Broughton with designated staff including a Coordinator, Senior OT and Senior Physio. The Manager states in the AQAA that a recent evaluation shows that 90 of people referred show significant improvement and the majority are able to return home or to less supported settings. One resident spoken with on the rehab unit, who was planning to return home in due course, said that staff had done everything possible to assist his recovery. The expertise of the rehabilitation staff is also made available to other units at Thamesbrook. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 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, 10 and 11 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 planning is of a high standard. Plans are person centred and frequently up dated. Staff work closely with health care colleagues, including the visiting GP practice, to ensure that residents’ health care needs are met. EVIDENCE: Four of the five care plans looked at were of a high standard, showing the involvement of the resident and addressing all aspects of the person’s care and support needs. Notes on care plans show that they are ‘live’ documents with staff making amendments in the light of changes, further information or advice from health care staff. Risk assessments were up to date. It is recommended that risk assessments for the use of a hoist include the name of the hoist and size of sling. Staff explained that there was very unlikely to be any error as the Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 11 unit had only one type of standing hoist and slings were kept in each resident’s room for their own use. The care plan of the most recently admitted resident to one of the dementia care units, who had been at Thamesbrook for 3 months, was less comprehensive. For example there was no information about the resident’s oral health care, even though the care notes showed that the resident’s family had requested a referral to a dentist. Nor had a placement review taken place, which would have provided an opportunity for some of the issues raised by the resident and by her family to have been discussed more fully and action agreed. The Manager stated that the appointment of an Acting Deputy Manager, who will monitor care planning, should help ensure greater consistency. Records show that residents’ health care needs are given a high priority. Staff make prompt referrals to ensure that residents’ receive advice and treatment, including referrals to the visiting GP practice and to the Tissue Viability Nurse. Medication is provided by a local pharmacy and is safely stored in a locked room. With the exception of the two dementia care units, medication is handled by Registered Nurses. Care staff handle medication on the dementia care units, following training, using the Boots training package. Archived MAR sheets seen on residents’ files were fully completed. Interactions observed during the visit showed that residents are treated with respect and steps taken to maintain their dignity. Staff were seen to check that residents who were sitting in their rooms had everything they needed. Care plans show that residents’ wishes regarding end of life care are discussed with them. Staff try to ensure that residents are cared for at Thamesbrook rather than in hospital at the end of their lives. The Manager, who has a background in palliative care nursing, said that she is considering enrolling the service for the Gold Standard Award. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff provide good support to meet residents’ individual interests, cultural needs and contact with families and friends. EVIDENCE: Routines are adapted to residents’ needs and preferences as far as practical. Residents preferred times of getting up and of going to bed are noted on their care plans. Records and discussion with the Manager and with residents show that residents’ individual interests, spiritual and cultural needs are supported. Residents’ rooms contain possessions reflecting their interests, including newspapers, magazines and CDs. Records show that residents are supported by staff to regularly attend places of worship, while religious services are also held in the home. Staff take residents shopping individually to the nearby shops and stores on the Kings Road. A number of residents continue to attend day centres including Pepper Pot, the Caribbean Centre in North Kensington. An external consultant has been working with a number of residents to compile their life stories. The Manager commented that this work has proved positive, not only for residents who have had the opportunity for their varied and Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 13 interesting experiences to be heard but also for staff who have gained a fuller understanding of residents’ background and are therefore better able to meet their needs. Residents in the dementia care units have taken part in producing a mural with local artists. A Christmas party was taking place on Broughton on the day of the inspection, Some staff who were not on duty had come in on their rest days to help and to be part of the occasion. Lunchtime was observed on Sloane Square, one of the dementia care units, where a pleasant, relaxed mealtime was ensured by staff. Residents were seen to be offered a choice of dishes at the time, rather than having to choose the day before. All of the residents ate well with prompting from the experienced staff present, who engaged people in conversation while discreetly supporting those who needed assistance. Staff from the kitchen were seen to visit to check on what was being eaten and whether anything additional was needed. Residents spoken with on Broughton commented that they especially enjoyed the opportunity to have a cooked breakfast. Records show that staff monitor residents nutritional needs and take action where there are concerns, for example when a resident looses weight. The Chef has recently attended a course on advanced nutrition for elderly people. The Manager said that the service is looking at ways to implement the Chef’s learning from the course to further improve the home’s catering. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 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 and 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. The open culture of the home means that residents and their families feel able to express any concerns or complaints. The welfare and safety of residents is given a high priority but safeguarding procedures must be followed consistently where there are concerns. EVIDENCE: The service has an established complaints procedure, although this is not widely displayed in the home, nor is it currently provided to new residents as part of the service user’s guide. All residents confirmed in the questionnaires returned that they knew how to make a complaint. Records seen also show that issues raised by relatives and residents are recorded on their daily notes. However steps need to be taken to ensure that the complaints procedure is made more widely available and that all complaints and concerns are collated, including action taken. The Commission has been notified of incidents and concerns over the past 12 months where staff have taken prompt action to ensure that residents’ welfare, safety and rights are protected, for example regarding access to their personal allowances. While generally staff have a high awareness of safeguarding procedures, it was of concern that on one of the dementia care units, where Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 15 one resident had assaulted another on a number of occasions, the established procedure was not followed. Steps were taken to protect residents but there were no record of a safeguarding referral or of subsequent meetings. It is unclear whether relatives were informed of the concerns or of action proposed. Nor was the Commission notified of the assaults. The Head of Provider Services confirmed that all staff at Thamesbrook would be attending training in safeguarding policies and procedures starting the following month, in January 2010. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 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 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. Accommodation is of a good standard, attractively decorated and with a range of specialist equipment. The hygiene and cleanliness of the building is given a high priority. EVIDENCE: Thamesbrook consists of 5 self contained units, each with a sitting/ dining room, kitchen, assisted bathrooms and office. All bedrooms are single rooms of a good size, with en suite shower rooms. There are well kept gardens and a sheltered first floor terrace. All floors are accessible by means of a large lift. There is a programme of regular redecoration and maintenance. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 17 The Manager stated that visits have been made by staff from the University of Stirling who are advising on changes to the environment in the dementia care units to better support residents. The building was clean at this unannounced visit, with no unpleasant odours. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 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. Residents are supported by an experienced and well trained staff team. EVIDENCE: The rotas show that there are sufficient staff on duty, including at night, to meet residents’ needs. Time is included in rotas for a formal handover, during which written information is exchanged regarding each person on the unit. In addition to nursing and care staff, there is a team of catering, administrative and cleaning staff. A handyman is also employed. Staff are recruited by the Manager and the Department’s HR team, who carry out criminal record and other checks. The Manager confirmed that PIN numbers are regularly checked for all Registered Nurses, including those from agencies. All vacant posts have recently been advertised, including the Deputy Manager and Dementia Care Team Leader and interviews are planned for January 2010. The home has an established induction for RGNs and for care assistants. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 19 All staff have access to accredited training in line with their professional development plans. A very good level of NVQ qualified staff has been achieved with all care assistants enrolled on or completed NVQ 2 or 3. Three RGNs are enrolled on NVQ4. Training records show that staff attend mandatory training, including refresher training and as discussed under standard 18, all staff are booked to attend training/refresher training in safeguarding from January 2010. A resource room has been made available for staff to use on the ground floor, which is equipped with laptops, books and journals. Staff are supported through regular staff meetings and supervision. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 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, 33, 35, 37 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 of the home continues to ensure a professional approach, which focuses on the needs of residents. EVIDENCE: The Manager has been in post since the end of July 2009 and has applied for registration with the Commission. The Commission was kept informed of management arrangements at the home following the departure in May 2009 of a long-serving Manager and the appointment of an interim Manager. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 21 The current Manager has a background in palliative care and was previously the Manager of a Hospice. While she has not had a full management team in place at the home, she commented on the good support she has received from senior staff in the Royal Borough. Discussion with staff and feedback from residents indicates that a professional and person centred approach is well established at Thamesbrook. The views of residents and relatives and carers are regularly sought and they were involved in the selection process for the new Manager. The finances of residents who are unable to manage their financial affairs and who do not have someone who can have Power of Attorney, are handled by the Adult Social Care Finance Team. Records of residents’ financial transactions were not looked at during this inspection. The majority of record keeping is of a high standard, however staff must ensure that a daily entry is made for each person, noting nursing and other care provided and any significant events. The Royal Borough’s Health and Safety team visit regularly, undertaking risk assessments, checks and providing advice. The Fire Safety Risk Assessment was recently reviewed. A visit by the Food Safety Team on 14th October 2009 gave the kitchens a 4 star rating. The Manager confirmed that the small number of recommendations made had been implemented. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 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 2 X 2 X X 4 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard OP1 OP3 OP7 Regulation 5 and 6 14 15 Requirement An up to date service user’s guide must be provided to new residents. A record of pre-admission assessments must be available for all residents. Steps should be taken to ensure that standards of care planning are consistent throughout the home. Plans should include details of oral health care. An initial review must take place within 6 weeks of the person moving to the home. A copy of the complaints procedure must be made available to each resident. A record of all complaints must be kept, including action taken. Safeguarding procedures must be consistently followed. A daily entry must be made for each resident, noting nursing and other care provided. Timescale for action 28/02/10 31/01/10 28/02/10 4 5 OP7 OP16 15 22 31/01/10 31/01/10 6 7 OP18 OP37 13 Schedule 3 31/01/10 31/01/10 Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is good practice to name the type of hoist and size of sling in all moving and handling assessments. Thamesbrook DS0000033393.V378696.R01.S.doc Version 5.3 Page 25 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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