Care Home: Thorndale

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What the care home does well There is sufficient detail of information available within the care plans that identify the health, social and emotional needs of the people that use the service, this enables the staff to provide the required level of support for individuals. The staff recruitment, selection and training procedures are robust this ensures that the people using the service are cared for by staff that are suitable for the roles within which they are employed and appropriately trained to fully support the people using the service. The management of the home is proactive the views of people using the service are listened to with the aim of improving the service. What has improved since the last inspection? This was the first key inspection. What the care home could do better: In addition implementing the initial safeguarding referral process ongoing contact should be maintained with the contact person within the safeguarding team. This will ensure that safeguarding referrals are investigated without delay and people using the service are protected from harm. The service agreements within the care plans of people using the service need the details of the Commission for Social Care Inspection updated. CARE HOMES FOR OLDER PEOPLE Thorndale Towells Land Malham Drive Kettering NN16 9FS Lead Inspector Irene Miller Unannounced Inspection 16th May 2008 10:30 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 Thorndale DS0000071448.V364687.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. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thorndale Address Towells Land Malham Drive Kettering NN16 9FS 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) 01536 526380 thorndale@shaw.co.uk www.shaw.co.uk Shaw Healthcare (de Montfort) Ltd On Secondment - Acting Manager - Joan Spicer Care Home 60 Category(ies) of Dementia (60), Old age, not falling within any registration, with number other category (60) of places Thorndale DS0000071448.V364687.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 Dementia - Code DE. The maximum number of service users who can be accommodated is: 60. 2. Date of last inspection: N/A Brief Description of the Service: Thorndale Care Home is a purpose built residential home which opened in December 2007. The home is registered to care for up to 60 older people to include people living with a diagnosis of dementia. The home is set out over three floors on each there are twenty en suite bedrooms, two lounge diners with small kitchenettes. Bathrooms with assisted bathing equipment and shower facilities. There are two passenger lifts that provide access to all floors. The home is situated within a residential housing estate on the outskirts of Kettering Town Centre. The people that use the service are placed under funding contractual arrangements with Northamptonshire County Council and Shaw Healthcare (De montfort) Limited. Weekly fees are charged at the County Council rates in the region of £504.22 with variations dependent upon the assessed needs of residents. Additional costs are required for individual expenditure such as chiropody, newspapers, toiletries and hairdressing services. The Statement of Purpose and Service User Guides which set out the range of services and the day to day routines at the home are made available to residents and visitors in a written format. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 5 Thorndale DS0000071448.V364687.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 the people who use this service experience good quality outcomes. The focus of all inspections undertaken by the Commission for Social Care Inspection (CSCI) are based upon seeking the outcomes for Service Users and their views of the service provided. This visit was unannounced and focused on the ‘key standards’ under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for older people. During this visit time was spent exploring how the people that use the service are protected from harm (safeguarding) time was spent with the people that use the service and staff. Specific questions were asked to establish how safe people felt living at the home and to determine the staffs understanding of ‘safeguarding’ people using the service. In addition records and policies on the safeguarding procedures were looked at. The care needs of three people living at the home were looked at in depth this involved looking through written information available on their care, such as care plans (a care plan sets out how the home aims to meet the individual service users personal, healthcare, social and spiritual needs). Discussions took place with residents, staff and visitors and observations of staff and service users interactions were made, with an aim to establish if service users were satisfied living at the home. Records in relation to staffing, how the home responds to concerns and complaints, the management of medication and the homes general policies and procedures were viewed. Prior to the visit CSCI had sent out to the home an Annual Quality Assurance Assessment (AQAA) for the registered provider to complete to provide the opportunity for them to self assess their performance. In addition CSCI also sent out to the home a selection of satisfaction questionnaires to residents, visitors, staff and healthcare professions involved with the home to complete. The provider had returned the AQAA to CSCI prior to this visit-taking place, and this gave supplementary information on the homes management and administration, processes. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 7 The satisfaction surveys returned to CSCI gave additional information on the views of people using the service and those who work and visit the home on a professional and personal level. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 9 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 Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 10 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): Standard 3 (Standard 6 is not applicable to this service) Quality in this outcome area is good. Information is made available to people who are considering moving into the home, this enables them to make an informed choice as to whether the home is right for them and that their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the care plans viewed there was records of pre assessments having been completed prior to the resident moving into the home. The assessments had identified the health and social care needs of the prospective residents and had formed the basis of the care plans. Within the care plans there was information on each of the residents individual preferences and social contacts the plans contained a ‘living history’ that gave some insight into the persons personality and lifestyle prior to moving into the home this included their and likes and dislikes, hobbies and interests. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 11 This information is useful when providing care for people living with advancing dementia whose ability to verbally communicate may be difficult. In discussion with the staff it was confirmed that prospective residents and their families are provided with a copy of the homes Statement of Purpose and Service User Guide available, although many of the residents living at the home had moved into the home through transferring from other Shaw Healthcare Homes, and were already familiar with the homes policies and procedures. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9 & 10 Quality in this outcome area is good. In general the health and personal care needs of people living at the home are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the care plans viewed there was information available on the individual health and personal care needs of the people using the service, this included information on their medical history, and the health care support required from healthcare professionals who are involved in the persons care. There were records available to demonstrate that peoples weight losses and gains are monitored and that appropriate action is taken to address any concerns in this area of care. The individual’s capabilities and areas requiring staff support were recorded within the care plans, there was assessments on mobility and pressure area Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 13 care and the assessments had identified what assistance was required with and moving and handling and pressure relieving equipment required. There were records of the assessments having being regularly reviewed. Records were available of accidents and incidents, when people had sustained an injury, such as falls and body charts that indicated where injuries had been sustained. Risk assessments were in place to identify the control measures in place to identify areas of risk and reduced the likelihood of accidents for each individual. There was information within the care plans for staff to follow on how best to communicate with people living at the home who’s ability to communicate had been effected through sensory loss and dementia. There were records within the care plans of people being seen by their general practitioner, and other healthcare professionals, such as the community psychiatric nurse (CPN), specialist consultants, opticians and dentists, and records were kept on changing needs. Comments received from healthcare professions surveys were in the main positive , with comments such as the staff are cheerful, respect the dignity of clients and manages medication issues well. However within the comments we received there was some concern about all people using the service being registered with the same general practitioner. Which raised questions about choice and continuity of care especially when in some instances a person may have been registered with the same GP for a number of years. The medication storage and administration systems were viewed and found to be generally satisfactory. The home had notified CSCI of medication errors prior to this inspection visit and had taken appropriate action to retrain all of the staff on the administration of medication. The team leaders on each of the groups hold the responsibility for the administration of medication and in discussion with the staff it was confirmed that appropriate training was provided and this was backed up by certification. During the course of the visit the staff were observed to treat people using the service and visitors with respect and courtesy. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 14 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): Standards 12,13,14 & 15 Quality in this outcome area is good. People using the service are supported in making choices as to how they wish to live their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit the people living at the home were observed to spend time within the communal areas and within their own private bedrooms. In discussion with people they confirmed that they are supported in pursuing their own interests. The home employs two activity co-ordinators, and the care staff are encouraged to socialise with the people living at the home, to spend time with people rather than focusing on household tasks. Within the care plans there was records of when people had been involved with an activity. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 15 Inspection record and report - quality monitoring form me of inspector: Miller me & address of service pected: ndale 71448 of inspection: /08 e of inspection Key Inspection Local office & region: Leicester EM Registration category: CRH Date passed to regulation manager: 20/04/07 Random Inspection New quality rating Date of RM review: Thematic Probe Level 3 New vious quality ng Registration e of regulation manager: Tagon pection record. ality indicators Inspector’s self assessment comments Regulation manager’s comments dwork Planning Yes evant evidence from h outcome area is ewed and this is orded. Yes otheses are mulated to focus work activity. Yes nge of fieldwork hods are used to hypotheses. t Fieldwork Analysis Yes ence collated from ources is marised. ements based upon the Yes ence are recorded for each ome area. pection report. Inspector’s self Regulation manager’s ality indicators assessment comments comments vice information & conditions of registration vice information and ditions of stration are sfactory. Yes ef description f description udes the services Thorndale Yes DS0000071448.V364687.R01.S.doc Version 5.2 Page 16 The staff were observed to spend time with the people living at the home doing group and individual activities. In discussion with staff, visitors and observations made during the visit there was an awareness of being flexible with activities to ensure they are individually tailored to the needs, abilities and preferences of each person. There were risk assessments in place that identified the risks surrounding the activities of individual people living at the home, such as being out unsupervised within the community, the assessments were realistic and aimed to protect the person without infringing on their human right to exercise choice, freedom and independence and to take risks. The group kitchen areas provide a facility to allow for flexibility in the provision of drinks and snacks, it was observed that drinks were readily available for the people using the service to access, relatives were seen to have access to the kitchen areas within the groups to make drinks whilst visiting. In discussion with staff and visitors it was confirmed that the people using the service are encouraged to eat a balanced diet and drink plenty of fluids. In discussion with the staff it was confirmed that the menus had recently been reviewed to include a greater variety of dishes and portion sizes had been increased. Time was spent with people living at the home over the evening, during which the staff were observed to offer support to people who required this, the people were given choices and in discussion with people they said that they were satisfied with the meals provided. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 17 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): Standards 16 & 18 Quality in this outcome area is good. People using the service can be assured that any concerns they may have will be listened to and acted upon. When safeguarding referrals are made ongoing communication between the service and the safeguarding team, would ensure that the referrals are dealt with promptly and without delay and that people using the service from are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were details on how to complain within the homes statement of purpose and service users guides. Within the front entrance of the home, there was information available for people that use the service and visitors on how to raise any concerns or complaints with the provider, and there was a suggestions box available. Within all of the care plans viewed there was a service agreement available that outlines the terms and conditions of residency at the home, it was noted that the contact details for CSCI were not current and in need of updating. Relatives spoken with during the visit confirmed that they were pleased with the care provided at the home, and said that if they had any concerns about Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 18 the care or service provided, they would feel comfortable discussing these with the Manager and confident that there concerns would be addressed. One concern had come to the attention of CSCI since the home has been registered; the provider had conducted an investigation into this concern and CSCI are satisfied that this was dealt with appropriately. A safeguarding alert was in the process of being investigated by the local authority safeguarding team. It was confirmed that the service had followed their procedure for reporting safeguarding concerns, and that interim steps had been put into place to ensure the protection of the vulnerable person. However there was a delay in action being taken by other agencies involved in the safeguarding process and it is thought that this was due to the details of the allegation being recorded on an ‘incident’ reporting form, and this form not being immediately identified as a safeguarding alert by the local authority. The Shaw Healthcare ‘responding to abuse’ policy refers to the importance of maintaining contact with the local authority safeguarding team in addition to supplying a written record of the safeguarding details. On this occasion following initial contact having being established both in writing and verbally there was delay of several days before any further action was taken in response to the allegation. The Annual Quality Assurance (AQAA) that was submitted by the provider to CSCI prior to the visit had identified that the outcome area of ‘complaints and protection’ did not require any improvements to be made. In discussion with people using the service they said that they liked living at the home that they felt safe speaking with any member of staff, a group of people using the service were asked if they knew who the manager was at the home, all said they did not know, but said they could speak with any of the staff if they had any worries. The people using the service were asked about what information had been provided the inform them of how to complain; they said that they could not remember being given any information on how to raise any concerns or complaints. However they said that they would speak with any member of staff if they had any concerns or worries, that the staff were very nice and they know they would listen to them. In discussion with the care staff on duty they demonstrated that they had an understanding of the importance of ensuring that people living at the home are protected from abuse and an awareness of the basic reporting procedures. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 19 Within the staff training records viewed there was certificates available to evidence that staff had received training on recognising different types of abuse and on the safeguarding adults policy and procedures. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 20 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): Standards 19 & 26 Quality in this outcome area is good. People using the service are provided with a modern, pleasant and clean environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A limited tour of the building was conducted to include communal areas, the kitchen and laundry facilities, and a sample viewing of resident’s bedrooms. The communal areas were clean and homely and there was a mix of seating available to include recliner chairs. People living at the home were observed to move around the groups freely, although key pad access is required to enter and exit other groups within the building. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 21 The home is of modern design and steps had been put into place to give the home a lived in feel to include pictures, ornaments and soft furnishings. The bathrooms and WC’s were clean, and there was equipment available to reduce the risk of cross infection. The bedrooms viewed were clean and personalised to contain small items of personal furniture, ornaments, photographs and pictures. The laundry facilities were clean and tidy. The kitchen was viewed during the visit there were records of food hygiene checks having been carried out regularly and staff were seen to observe good food hygiene standards and to wear protective clothing. A secure garden /patio area is available, as the home is new this area would benefit from landscaping and having flower borders, raised flower beds available to make this a more welcoming and pleasant outdoor area for people to spend time in. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 22 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): Standards 27,28,29 & 30 Quality in this outcome area is good. The staff have the skills and experience to provide good quality care for the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection visit there was sufficient staff on duty to care for the people using the service. The recruitment files of three staff were viewed and documentation was available to demonstrate that pre employment checks had been carried out on the staff prior to taking up employment at the home. These included checks being carried out on the protection of vulnerable adults register (POVA) first, and with the criminal records bureau (CRB). There was evidence of two references having been obtained for each member of staff prior to staff taking up employment. All staff that take up employment at the home embark upon a four day induction training programme that provides the underpinning knowledge of the organisational policies and procedures, the induction training covers moving and handling, fire awareness, infection control, first aid, medication, dementia care, and challenging behaviour. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 23 The staff surveys returned to CSCI indicated that they were happy working at the home, comments such as, ‘the company always make sure training is up to date’, ‘ supervision is regular, I feel very well supported from the managers’, ‘sometimes communication is a bit slow but its done finally’, ‘the home does well at meeting residents needs and staff support’, ‘sometimes communication could be improved’. In discussion with the staff on duty they expressed satisfaction at working at the home and confirmed that they were provided with training to include training to gain a National Vocational Qualification in Care (levels 2 & 3). There were records available of staff receiving regular one to one supervision with their designated supervisor, the purpose of the one to one supervision is to provide staff support and identify areas for self-development. In discussion with the staff it was confirmed that each group holds their own regular meetings to plan activities and to review the care needs of the people living within the groups. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 24 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): Standards 31,33,35 & 38 Quality in this outcome area is good. The home is run in the best interests of the residents, and systems are in place To promote their health, safety and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered Managers post was at the time of the visit vacant, an interim manager has been covering the home to ensure it is effectively managed. Shaw Healthcare has informed CSCI of the management arrangements and in discussion with the senior person on duty it was established that interviews for the manager’s post had recently taken place and it was anticipated that a new manager would soon be appointed. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 25 Quality assurance systems are in place, and this include the distribution of questionnaires to people using the service and their families, this provides a formal opportunity them to have their say on how the home can continue to improve on the service provided. The homes Annual Quality Assurance Assessment (AQAA) was submitted to CSCI within the timescale and provided a self-assessment of the services provided by the home in which areas for improvement had been identified Within the Annual Quality Assurances Assessment (AQAA) submitted to CSCI The home had identified the need for an improvement on how the results of the quality surveys are made available to people living at the home and their families. To ensure that all are fully informed on the outcomes of the surveys, and the organisations plans for improvements. One area identified for improvement by the home was the accident and incident reporting procedures; these had been updated and improved to ensure that regular monitoring takes place by a representative from within the organisation. Regular internal health and safety checks identify areas for improvement to ensure standards are maintained, and Health & Safety refresher training is provided annually. The financial interests of people using the service are safeguarded through the home carrying out regular audits and there were service contracts in place. The staff support systems ensure that each member of staff receives one to one supervision with their designated team leader to identify areas for selfdevelopment. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 26 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 3 8 3 9 3 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 2 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 2 X 3 X 3 X X 3 Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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. 1 Refer to Standard OP18 Good Practice Recommendations In addition to written information being provided when referring to safeguarding, verbal contact should be maintained with the safeguarding ‘contact’ person throughout the process. This will ensure that safeguarding alerts are addressed without delay and people using the service are fully protected from harm. Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Thorndale DS0000071448.V364687.R01.S.doc Version 5.2 Page 29 - 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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