Care Home: Thorncliffe House

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What the care home does well The resident`s benefit from a well maintained home that offers access on all floors by either a lift or a specially fitted stair lift. Equipment and adaptations are available to help physically disabled and frail people with their personal care. Staff have a good rapport with residents and their visitors and this contributes to the welcoming atmosphere in the home. The manager is always willing to make improvements and is committed to ensuring that the staff works in the best interests of the residents. The quality of food is good and service users likes and dislikes are taken into account and they can choose from a number of options on the menu what they would like to eat. The menus also take into account any dietary/cultural needs and families have been involved to offer advice to staff where needed. Good training opportunities are available for the staff and the manager ensures that she also attends regular training courses. Staff deals with personal care tasks discretely and professionally and offer reassurance to those residents who at times become upset and unsettled. The home is managed in a way which keeps people safe and people recognised this was a safe environment to be in. Several residents returned surveys and comments made were, "I always join in and I will try any activity" "The carers are always there to help you" "I have no complaints and if I did I would speak to the manager". One staff survey was returned and this stated " that the care in the home is excellent and that the cook caters for each individual residents taste". What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE Thorncliffe House 15 Thornhill Park Sunderland SR2 7LA Lead Inspector Mr Clifford Renwick Key Unannounced Inspection 9th July 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thorncliffe House Address 15 Thornhill Park Sunderland SR2 7LA 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) 0191 510 9736 F/P philip@thorncliffe-house.com Mr Philip Longmore Mrs Margaret Elizabeth Kirkwood Care Home 24 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (24), Physical disability (2) of places Thorncliffe House DS0000059954.V366726.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 only – Code PC 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 - maximum number of places 24 Dementia - Code DE, maximum number of places 8 2. Physical Disability, Code PD, maximum number of places 2 The maximum number of service users who can be accommodated is: 24 11th July 2007 Date of last inspection Brief Description of the Service: Thorncliffe House is a registered care home, which provides permanent accommodation with personal care and support for up to a total of twenty-four older people, some of whom may have dementia needs. Within this total, the home may also provide a service to a limited number of adults with a physical disability. Nursing care cannot be provided. The property is a three storey Victorian detached house, with bedroom accommodation and WCs on each floor; bathing areas are located on floors one and two. A passenger lift serves all three. Located on the ground floor, are a large lounge and a further open-plan lounge/dining room for communal use. Situated in a quiet cul-de-sac close to the centre of Sunderland, the home is near shops, parks and transport networks. There is a large, well-kept garden to the front, which Service Users may enjoy in fine weather and at the side, a wide secure area with a ramp, which enables access for people with impaired mobility. The rear ‘yard’ is soon to be converted into a pleasant patio. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 5 The home has completed building work to the rear of the building to extend the property to provide another five residential places, while at the same time improving the access and standards of the existing building and its grounds for service users. The home has developed a Statement of Purpose and Service User Guide that inform prospective and current service users about the service, the aims and how these are met. These and a copy of the recent inspection report are available in the home for anyone to read. The weekly fees are £402.00 to £417.00 per week depending upon care needs. Additional charges are made for hairdressing, personal items and newspapers and magazines. The owner provides toiletries, bubble bath and shampoos. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. Before the visit: We looked at: • • • • • • Information we have received since the last visits in July 2007. How the service dealt with any complaints & concerns since the last visit. Any changes to how the service is run. The provider’s view of how well they care for people. The provider in the annual quality assurance assessment (AQAA) submitted information to confirm what they are doing in the service. We looked at information we received in surveys from staff, residents and their relatives and other professionals who use the service. The Visit: An unannounced visit was made on the 9th July 2008. During the visit we: • • • • • • • • • • Talked with people who live in the home and also staff who were on duty. Held discussion with the Registered Manager and registered provider. Observed staff working practices. Looked at information about the people who live in the home & how well their needs are met. Looked at other records, which must be kept in relation health and safety and staffing. Checked that staff had the knowledge, skills & training to meet the needs of the people they care for. Looked around the home to make sure it was well maintained, safe and free of any hazards. Checked what improvements had been made since the last visit. Spoke with staff. We also focused upon looking at care files for 3 residents as a part of the inspection we refer to this as “case tracking”. And this involves looking at all records of the care for a named individual. We told the registered manager what we had found. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 7 The people who live in this home prefer to be known as residents therefore this term of reference is used throughout the report. What the service does well: The resident’s benefit from a well maintained home that offers access on all floors by either a lift or a specially fitted stair lift. Equipment and adaptations are available to help physically disabled and frail people with their personal care. Staff have a good rapport with residents and their visitors and this contributes to the welcoming atmosphere in the home. The manager is always willing to make improvements and is committed to ensuring that the staff works in the best interests of the residents. The quality of food is good and service users likes and dislikes are taken into account and they can choose from a number of options on the menu what they would like to eat. The menus also take into account any dietary/cultural needs and families have been involved to offer advice to staff where needed. Good training opportunities are available for the staff and the manager ensures that she also attends regular training courses. Staff deals with personal care tasks discretely and professionally and offer reassurance to those residents who at times become upset and unsettled. The home is managed in a way which keeps people safe and people recognised this was a safe environment to be in. Several residents returned surveys and comments made were, “I always join in and I will try any activity” “The carers are always there to help you” “I have no complaints and if I did I would speak to the manager”. One staff survey was returned and this stated “ that the care in the home is excellent and that the cook caters for each individual residents taste”. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: The care plans must include more detailed information as to what actions the staff takes in meeting the assessed needs. When developing the care plans written information must also be included about how staff meet social needs in order to reflect the positive practices that are currently being carried out. Staff should have appropriate seating when they are assisting residents at mealtimes. The pre printed medicines sheets that are in use should include the dates that medicines are administered and a written record should be maintained whenever medicines are omitted. The locks that have been fitted to the new bedroom doors must be adapted or changed in order that staff is able to access the bedroom in the event of an emergency. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 9 The manager must enrol on the NVQ 4 care module upon completion of the Registered Managers Award. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 10 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 Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A full pre-admission assessment of needs ensures that new residents are offered the right type of care at the home. Intermediate care is not provided. EVIDENCE: In looking at the file for the person most recently admitted to the home evidence was available to confirm that a detailed assessment had been completed prior to admission. The homes admission and assessment procedure ensures that residents can make an informed decision about coming into the home. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 12 Discussion with the manager also confirmed that prospective residents are given information before visiting the home that informs them how their care needs are to be met. The assessment information is then used to develop a written plan of care that demonstrates how staff will meet the assessed needs. This is discussed more fully in section 7 – 11 of this report. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. While clear improvements have been made to the care planning process and documentation, this needs further development to ensure that people receive care in a way that they prefer. Nevertheless, health care needs are effectively met and medication administration follows good practice. These ensure that residents’ general health and wellbeing are safeguarded and promoted. Staff interactions with residents confirms that residents are treated with dignity and respect at all times. EVIDENCE: Three files were looked at as part of this inspection and this process is known as case tracking and assists inspectors in assessing how staff are meeting residents needs. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 14 Each resident has a written plan of care that is followed by staff to meet the care needs. The care plan is formulated based upon the information obtained as part of the assessment process. In some instances not all of the social information obtained as part of the assessment process was developed into the care plan. Yet in practice staff was carrying out specific tasks that had been identified during assessment and were important in maintaining residents social interests. The care plans do not contain sufficient information that staff can follow. The care plans identify the needs and the objectives but there is insufficient information to demonstrate the actions that staff takes to achieve this. The care plan documentation that is currently in use is a standardised pre printed system that has sections that staff adds the written detail to. This should then clearly demonstrate what staff does to help people. For some people the information that was recorded to demonstrate how social and physical needs are being met was not recorded in the appropriate section of the care plan form. In discussion with staff and the manager they were able to speak in detail of the work that they were doing with individual residents and this confirmed that assessed needs were being met even though the level of detail was not recorded in the care plans. For example one resident whose assessment confirmed that they like to receive daily papers and a certain paper on Sunday does receive these but there is no reference in the care plan. Another person who has a professional sports background has been supported by staff to maintain links with a local football club that he played for. This is going to result in a visit to the local football ground where he will be treat as a guest of honour. And another person who likes to go to the local club whenever the Sunderland football club match is televised is supported by staff to do this. This level of work carried out by staff to support residents with their social interests is good but as stated there is insufficient reference to this in the care plans. Discussion held with residents confirmed that the “staff is very good” and the home is nice place to live in. The care plans are monitored and evaluated at least monthly to show staff if there are any changes needed to the records. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 15 And in discussion with the manager she confirmed that new documentation has been added to support residents with their health needs. This includes an assessment document to support people at risk from pressure sores. Risk assessments are also in place and these link in with the care plans and also the daily records that offer evidence as to how people spend their days. Records are also available to confirm that residents have access to health professionals when required. Senior staff is responsible for administered prescribed medication and all have undergone accredited training. The home uses a monitored dosage medication system (Nomad) and these are delivered to the home from the pharmacy on a monthly basis. At the same time any unused or unwanted drugs are collected and returned to the pharmacy. MAR (medication administration document) sheets had some minor shortfalls due to them being pre printed. The sheet shows the date the prescription was issued but not the date that the medication commences and as such leaves potential for error. Another area that needed addressing was where medication was not administered but staff had not recorded a written reason as to why. This was discussed with the manager who contacted the pharmacist with a view to having all of the administration sheets changed. The arrangements that were in place for the storing and recording of those medicines referred to as controlled drugs were discussed with the manager. As a result of this steps were taken after the inspection to provide a new secure lockable facility and a different type of record keeping in order to comply with the new guidelines issued by the Royal Pharmaceutical Society. As part of the assessment process residents are offered an option of retaining their medicines for self-administering. Residents sign a consent form to confirm whether they wish to retain their own medicines or whether they want staff to administer them. Comments from residents included: “Good meals” “I like to take part in the activities” “I am very happy here” Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 16 “I can’t use my hands but staff help me to join in the activities” Observations made during the visit confirmed that personal tasks are carried out in the privacy of resident’s rooms. Staff have a good rapport with residents and it was nice to see the humorous exchanges that took place during the day. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lead fulfilling lifestyles through exercising choice and control over how they spend their day. People’s lifestyle is good with regular contact being maintained with relatives and friends and the residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The home provides a range of spontaneous and planned activities both in the home and the local community. As previously stated in this report the staff have planned with some residents the opportunity to plan how they would like to spend their days. And one resident during the football season is supported to visit the local club for a drink and to watch the Sunderland match when it is being screened on satellite television. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 18 There is an activities coordinator in the home who keeps a record of the activities that have been organised during the week. This record also lists who attended. Information received in resident’s surveys confirmed that there were sufficient activities available in the home. Some of the activities that had recently been held had been a 100year birthday party, quizzes, videos, trips down memory lane and a trip out to a dinner dance. Gentle chair exercises are available and the home is liaising with the “falls advisor” for one resident so that has resulted in an individual exercise plan being implemented. One person who has particular cultural needs is supported by the staff and also with involvement of their family. This has resulted in the family showing the cook a particular way to cook some foodstuffs. Lunch was taken with the residents and this very tasty, hot and served in a well laid out dining room. Menus are available in both written and pictorial format and demonstrate a good choice of meals. Observations confirmed that residents are asked each day what they would like to eat form the choices shown on the menu. However residents confirmed that if they did not like what was on the menu then staff would always provide an alternative. Some residents required assistance to eat their meal and this was provided by staff. However as there was insufficient chairs staff did not sit with residents but crouched by their side when helping them to eat. This was discussed with the manager as it is more appropriate for staff to sit with residents when assisting them to eat. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clear accessible complaints procedure gives residents and their relative’s confidence that they will be listened to and taken seriously. Furthermore it provides information that is effectively used to improve the service. The manager and staff have a good understanding of local adult protection procedures, which helps to ensure the protection of residents from abuse. EVIDENCE: A complaints procedure is on display and information is also given out with the Homes Service User Guide. Discussion with residents confirmed that they had no complaints and if they did they would raise them with the manager or the staff. Surveys received from residents confirmed that they knew what to do if they had any concerns. A record is kept of any complaints or concerns raised by the residents or their relatives and also what actions have been taken to rectify these. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 20 The manager confirmed that all staff has undergone safeguarding adults training though this is not recorded on the staff training record. This training was confirmed as having being carried out by an external training agency. Local Authority safeguarding adults procedures are in place and all staff have read them. In discussion the manager confirmed that she ensures that refresher training is arranged as and when needed for all staff. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained and has a good range of facilities. This promotes a positive image for residents and furthermore ensures that they remain safe and well. EVIDENCE: During this visit we looked at all communal areas and also the newly created facilities in the extension to the rear of the building. The building was clean and tidy and did not have any unpleasant odours. The new extension has provided 5 new bedrooms all with their own en suite toilet facility and one of which has its own shower. In addition to this there is also a spa bath, a walk in shower, managers office, rear patio and seating area Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 22 and a “comfort” room that can be used for spa treatments or to see people in private. The locks that have been fitted to the bedroom doors are of a type that if a resident locks them from inside the room and leaves their key in the door, then staff cannot gain access to the room in an emergency. This was discussed with the manager who was advised of the need to ensure that staff must be able to gain access to resident’s bedrooms in the event of an emergency. And as such the current locks that had been fitted needed to be reviewed and possibly replaced. The furniture in the new bedrooms is of good quality and in discussion with the manager it was confirmed that this kind of furniture would be supplied to existing rooms as part of the ongoing refurbishment over the next 12 months. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well-trained, caring and committed staff is in post with good staffing levels. This ensures that staff has the knowledge and skills to care and support people. Residents are protected by the home’s robust recruitment procedures. EVIDENCE: At the time of the visit staffing levels were sufficient to meet the residents needs. Staffing rotas confirmed that consistent staffing levels are maintained. Each day one person starts work earlier than the other day workers to overlap with night workers in order to offer increased cover at what is a busy period of time in the home. The home have their own maintenance man who works 4 hours daily and deals with repairs and ongoing maintenance in the building. Robust recruitment procedures are in place that ensures all of the necessary checks are carried out before someone is employed to work in the home. A training file is in place and this confirmed that all staff has undergone NVQ Level 11 training and 2 staff has also undergone NVQ Level 3 training. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 24 Good opportunities are in place for staff to receive training that is relevant to their work. Staff have received training in Moving and assisting, fire safety, dementia awareness and food hygiene. And staff do not have to pay for any training they receive. The manager confirmed that staff are also undergoing health and nutrition training and will be undergoing a 13-week distance-learning course on equality and diversity. And training in falls prevention is organised to take place in August. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced manager is in post, which ensures that the service is effectively run in the best interests of the residents; that they are safe and well cared for and their rights are safeguarded. EVIDENCE: The manager is experienced and is in the final stages (last 4 weeks) of completing the Registered Managers Award. The delay in completing this training though not the manager’s fault is as a result of the manager having had 5 different assessors and this has caused additional difficulties. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 26 The manager confirmed that once she has completed the registered managers award she would be enrolling on the NVQ level 4 care course. The manager confirmed that she has attended all training courses that staff have attended in order to keep her skills and knowledge updated. Good management practices are in place and staff minutes of staff meetings confirmed that these are used to discuss practices and developments in the home. The manager carries out regular quality audits and from this actions are carried out to improve the service. The views of residents are sought and the manager ensures that these are used to develop services within the home. However this is not formulated into an annual plan showing how improvements are to be made. Appropriate records are in place to confirm how monies held on behalf of residents are managed. Good health and safety practices are in place and staff undergoes the necessary mandatory training which is updated as and when required. All staff recently received updated fire training from an external trainer and records available confirm that staff take part in regular fire drills and fire instruction. Environmental risk assessments have been completed to ensure that there are no hazards in the home. And a fire risk assessment is in place to ensure that staff are up to date with evacuation procedures and know what actions to take in the event of a fire. The accident records are in good order and clearly demonstrate the actions taken by staff in the event of an accident. Observations of staff practices confirmed that they follow correct health and safety guidelines with the exception of mealtimes. When as already stated in this report staff were crouching on the floor when supporting people to eat as opposed to sitting on a chair. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 X 2 X 3 X X 3 Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The care plans must contain sufficient information to demonstrate how staff meet assessed needs.(Partly met since last inspection visit) The locks that are fitted to the new bedroom doors must be adapted or changed. To ensure that staff are able to gain access in the event of an emergency. On completion of the Registered Managers Award the manager must begin training in NVQ 4 in Care. Timescale for action 31/12/08 2. OP19 23 (4) (c) (iii) 31/08/08 3. OP31 9 30/11/08 Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP38 Good Practice Recommendations The pre printed medicine administration sheets should show the date medication commences. The manager should ensure that staff has appropriate seating when assisting residents to eat their meals. Thorncliffe House DS0000059954.V366726.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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