Care Home: Thornton Leigh Care Home

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What the care home does well The service meets the health needs of those who use the service. The health of all individuals is promoted through the safe management of medication. Those who use the service are treated in a dignified and respectful manner. Those who use the service are able to have their self-esteem promoted through the provision of meaningful activities through the day and are able to maintain contact with their families and friends thus eliminating isolation. Those who use the service are enabled to be as independent in their daily lives as mush as possible. The nutritional needs of individuals are met through the food provided. Those who use the service are protected from abuse. Those who use the service have their self-esteem promoted through the provision of a well-decorated and hygienic environment. Those who use the service have their needs met by staff that are sufficient in number, are qualified and trained to do their job.Those who use the service benefit from receiving support form a service that is managed by an experienced individual. The financial affairs of individuals are safeguarded. Comments made during the inspection included: `I am confident that any complaints I have, if I had them, would be addressed` `I definitely feel safe here, I love my room, and the en suite there is a lot better for me` `You can do your own thing. I thank god for it, the Owners do their best for us` `The home is clean and the food is good` `It is lovely here, everything is lovely, the food and the staff` `I get choice and can go to sleep when I want` `The exercise keeps you fit` `Everything is ok` `Staff help to get me around and I am keeping well` `There are always things to do` `There is choice and alternatives with food` `My room is alright, they are good at listening` `Staff are very good` `I feel safe and on the whole I am happy` `The Manager is on top of things and on the ball` `The best thing about the home are the residents and the teamwork is good. l can`t think of anything that needs improving` `The Manager is always there` and is `hands on` What has improved since the last inspection? The service now ensures that the needs of individuals who come to live in the service are met through the obtaining of assessments prior to them coming to Thornton Leigh. Changes to the needs of individuals are now met through the reviewing of care plans on a monthly basis. Those who use the service and their families are now able to influence the running of the service through the recording of any received complaints. Those who use the service are now protected by the availability of information placing restrictions on staff in relation to their financial affairs and are protected by the proper recruitment of staff. The health and safety of individuals are now promoted through the availability of health and safety training for staff. Those who use the service are now able to influence the service through the holding of regular meetings, which ask for their views about the support and care provided. What the care home could do better: The service must ensure that any inductions undertaken by new staff are recorded so that there are familiar with their role within the service. Fire drills must take place every six months so that the health and safety of all is promoted. CARE HOMES FOR OLDER PEOPLE Thornton Leigh Care Home 42 Huyton Lane Huyton Knowsley Merseyside L36 7XG Lead Inspector Mr Paul Kenyon Unannounced Inspection 29th October 2008 09:30 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 Thornton Leigh Care Home DS0000021485.V372807.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. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thornton Leigh Care Home Address 42 Huyton Lane Huyton Knowsley Merseyside L36 7XG 0151-489-1950 0151 480 9703 ronvaltd@yahoo.co.uk 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) Mr Ronald William Baker Mrs Valerie Elizabeth Baker Mr Ronald William Baker Mrs Valerie Elizabeth Baker Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15), Physical disability over 65 years of age of places (15) Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 15 OP and up to 15 PD (E) Date of last inspection 19th February 2008 Brief Description of the Service: Thornton Leigh is owned and managed by Mr and Mrs Baker. Both are retired nurse tutors who also hold a recognised nursing qualification. The home is an older property, which has been well maintained and has many original features. This helps to promote a comfortable and homely atmosphere. Thornton Leigh benefits from an established garden, which is readily accessible to residents. The home is situated on a main road within walking distance of the shopping facilities of Huyton Village. The home is managed around the Christian Ethos. Prayer meetings are held twice weekly and daily readings from the bible are read at lunchtime for those residents who follow a Christian faith and wish to be involved. Residents who are non-Christians are also welcome at the home. Fees are currently charged at £327 per week with charges for hairdressing and chiropody. Thornton Leigh Care Home DS0000021485.V372807.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 2 stars. This means the people who use this service experience good quality outcomes. This was the main key inspection to be held at Thornton Leigh this inspection year (April 2008 to March 2009). The visit was unannounced and took place during the morning. The inspection included discussions with three individuals who live there and two staff members. Comments made are included within this report. Records relating to the care provided by the service were examined as well as a tour of the building undertaken as part of the visit. National Minimum Standards for older people were used to measure the quality of the care provided by the staff at Thornton Leigh. What the service does well: The service meets the health needs of those who use the service. The health of all individuals is promoted through the safe management of medication. Those who use the service are treated in a dignified and respectful manner. Those who use the service are able to have their self-esteem promoted through the provision of meaningful activities through the day and are able to maintain contact with their families and friends thus eliminating isolation. Those who use the service are enabled to be as independent in their daily lives as mush as possible. The nutritional needs of individuals are met through the food provided. Those who use the service are protected from abuse. Those who use the service have their self-esteem promoted through the provision of a well-decorated and hygienic environment. Those who use the service have their needs met by staff that are sufficient in number, are qualified and trained to do their job. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 6 Those who use the service benefit from receiving support form a service that is managed by an experienced individual. The financial affairs of individuals are safeguarded. Comments made during the inspection included: ‘I am confident that any complaints I have, if I had them, would be addressed’ ‘I definitely feel safe here, I love my room, and the en suite there is a lot better for me’ ‘You can do your own thing. I thank god for it, the Owners do their best for us’ ‘The home is clean and the food is good’ ‘It is lovely here, everything is lovely, the food and the staff’ ‘I get choice and can go to sleep when I want’ ‘The exercise keeps you fit’ ‘Everything is ok’ ‘Staff help to get me around and I am keeping well’ ‘There are always things to do’ ‘There is choice and alternatives with food’ ‘My room is alright, they are good at listening’ ‘Staff are very good’ ‘I feel safe and on the whole I am happy’ ‘The Manager is on top of things and on the ball’ ‘The best thing about the home are the residents and the teamwork is good. l cant think of anything that needs improving’ ‘The Manager is always there’ and is ‘hands on’ What has improved since the last inspection? The service now ensures that the needs of individuals who come to live in the service are met through the obtaining of assessments prior to them coming to Thornton Leigh. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 7 Changes to the needs of individuals are now met through the reviewing of care plans on a monthly basis. Those who use the service and their families are now able to influence the running of the service through the recording of any received complaints. Those who use the service are now protected by the availability of information placing restrictions on staff in relation to their financial affairs and are protected by the proper recruitment of staff. The health and safety of individuals are now promoted through the availability of health and safety training for staff. Those who use the service are now able to influence the service through the holding of regular meetings, which ask for their views about the support and care provided. 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 8 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 Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 9 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. Standard 6 is not applicable to the service at present. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who come to live at Thornton Leigh have their needs met through the assessment process. EVIDENCE: One person has been admitted since the last inspection. This person is privately funded and as a result, the service had assessed this individual using its own assessment. There was evidence that this had occurred and had been done before the person had come to live at Thornton Leigh. Information relating to this person’s needs had also been obtained from a hospital while the person had been transferred. Issues in the assessment mainly focussed on health needs with some reference to social needs of the person. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service have their needs met by care plans devised by the service, which are regularly reviewed. The health of individuals is maintained through the actions of the staff team. The management of medication promotes the health and safety of all and the self-esteem of individuals is maintained through the actions of staff. EVIDENCE: Three care plans examined relating to three individuals, all of whom the Inspector spoke with during the visit. Details of the health and needs of individuals were gained form the interviews and this allowed the Inspector to then examine care plans to see if these needs had been translated to care plans. The main needs of these individuals had indeed been included in each care plan. There was evidence that all care plans had been reviewed on a Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 11 monthly basis and in cases where needs had changed, there was evidence to suggest that care plans had been amended to reflect these changes. Each care plan included the actions needed by staff to best support each person. Discussions with the Manager suggested that relatives were to be contacted to agree care plans and to update them with respect of any changes in needs. Daily records back up all care plans. Interviews with two individuals included gaining views about their health. While both stated they were well, they stated that when they became unwell, Doctors or other health professionals visited them. All health care appointments are outlined in daily records. It is recommended that health appointment records be devised for easier reference of progress of health. The health needs of individuals are outlined in care plans. All individuals are registered with a Doctor and there was evidence that district nurses visited at least two individuals and records are retained by the service. The day of the visit coincided with influenza vaccinations for people and these were being carried out by Community Nurses had been arranged for all and nurse visited during the visit. Other health appointments included chiropody visits. All individuals are weighed on a regular basis with the last monitoring done in October 2008. When there is a change in weight, comments are made whether a loss or gain in weight is recorded. Some people have continence needs. There was evidence that continence care training had been provided to staff. Weekly activities include light exercise for individuals and this was confirmed through activity records and interviews with individuals. Medication is stored in a secure purpose built trolley that is locked when not in use. A medication policy is in place relating to the ordering, administration and disposal of medication. All medication administration records are correctly signed for October 2008. Photographs identify each person. No one selfadministers at present. It was understood that one person had been responsible for their own medication did but had asked service to take this administration over. There was evidence that only some staff administer medication and samples of their signatures are in place. Information on medication prescribed is retained. The morning medication round was observed. The responsible person approached each person with medication being administered in a friendly and unhurried manner. One person has a visual disability and it was noted that they had been informed and supported when taking medication. Preferred terms of address of individuals have been identified and evidence was available on the nameplates on each person’s bedroom. Some are more informal that others. One person during the visit was observed being addressed in a formal yet preferred manner. All individuals who were interviewed were happy with the level of support given to them by staff in respect of their dignity. Interactions between staff and those who use the service were noted to be friendly and respectful. A payphone is available in the Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 12 dining room and can be used for individuals to make private calls. All laundered clothing is discreetly marked and there was evidence that mail addressed for one individual had been unopened before it was passed on to the addressee. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service are provided with activities on a daily basis. Individuals are able to ensure that they are not isolated and have contact with the wider community. Individuals are able to have their self-esteem promoted through the practices of the service enabling them to be as independent as possible. Meals meet the nutritional needs of individuals. EVIDENCE: An activity plan is on display outlining the daily activities available. These include light exercise, hairdressing, aromatherapy, evening prayer meetings, dress shop, sing-a-longs and a Christmas Fayre planned for December. These were confirmed through interviews with individuals. The same interviews confirmed that individuals had their own routines and got up when they wanted and that this was respected although people generally got up early each morning. A trip for all was due to take place to Southport for the day and Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 14 again individuals had been informed that this was to take place and were looking forward to it. Interviews confirmed that individuals are able to receive visits from family members and friends and this was also confirmed by the visitors’ book. Community contact also takes place through the visits to the home by those planning activities e.g. sing-along, aromatherapist. Personal possessions were noted to be included in bedrooms and in some cases, to a significant degree. Observation of care practice noted that individuals mobilise through the home independently and are encouraged to express choice. This reference to making decisions was confirmed through interviews with those who use the service. A financial policy is in place suggesting that those who are able to manage their own financial affairs are enabled to do so and those who have family involvement in this do the same. It is only in the minority of cases where the home will deal with the financial affairs of individuals. One person confirmed that she had managed her finances and allows the manager to provide safekeeping facilities for her monies. No individuals are on special diets at present as confirmed through care plans. One person has developed a poor appetite and this has been included in daily records. Nutritional supplements have been made available to this person. Records are in place in respect of people’s preferences with foods and any allergies they may have. The service has done a lot of consultation with those who use the service since the last inspection in respect of meals and has gained an indication of their views. Three individuals were interviewed and asked about meals. All are satisfied with the standard of food provided. They confirmed that choice and alternatives are available and the menus confirmed this. A menu is on display in the dining room indicating that the two main meals of the day are cooked with lunch being the main meal. A dining room is available but not all individuals use this for their meal and have the opportunity to eat in their rooms if they wish. Breakfast is served in people’s rooms in the morning if they wish. Records of food provided indicated that alternatives are offered where available. The kitchen is an organised facility with freezers and refrigerators well stocked with fresh fruit and vegetables also available. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 15 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who live at Thornton Leigh are able to have a say in the running of the service through the complaints procedure and are protected from abuse. EVIDENCE: A complaints procedure has been made available to all individuals and this is on display in each bedroom. The procedure outlines the action that the individual and their family can take if they are not satisfied with the service provided. Interviews with three individuals noted that while they had no complaints, they knew they could speak to the manager and were confident that they would be listened to and action taken. A complaints record is now maintained. Two complaints received since the last key inspection. The records outlined the nature of the complaint, action taken and whether the complaint had been resolved. A Local Authority procedure is in place for the reporting of allegations. No allegations have been made since the last inspection. Interviews with staff confirmed that they had received abuse awareness training although one stated that they were not aware of the whistle blowing procedure. This is raised as a recommendation in this report. A policy is now in place placing restrictions on staff being involved in the financial affairs of those who use the Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 16 service. The service has a challenging behaviour policy in place for dealing with physical and verbal aggression although this is not applicable at present. The three individuals interviewed all stated they felt safe living at Thornton Leigh Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service benefit from living in a well maintained, well decorated and pleasant environment. EVIDENCE: The building benefits from a rolling maintenance programme. Three new en suites noted at the last inspection continued to be used and one individual stated that this facility had been of benefit to them. The building was clean, tidy and free from unpleasant smells. A tour of the building noted that there were no decorative issues other than acceptable wear Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 18 and tear. The Manager stated that some areas were to be repainted with steps taken to minimise disruption to individuals. The tour of the premises included an examination of the laundry area. This is a well-organised and well-equipped faility with industrial washing and drying appliances in place. A sluice is also available in this area. Floors are nonporous and handwashing facilities are available close by. Protective clothing is available to staff and is located in the laundry. No offensive odours were noted in any part of the building during the visit. Two individuals interviewed stated that they were very happy with their rooms. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service have their needs met by staff that are sufficient in number, are qualified to perform their role and receive the training to meet their needs. Individuals do not benefit from a staff team who have received induction into their job role. The recruitment process protects all. EVIDENCE: Staff rotas indicated that there were five members of staff on duty during the morning of the visit with this going down to three in the afternoon but increased numbers of staff in the morning suggested a response to the needs of individuals during a busy time of the day. Ancillary staff are also employed which include a domestic member of staff and a cook. It was understood that the regular cook was on leave the week of the visit but that an agency cook had been used to replace him. A rota is available indicates that staffing levels are maintained. The manager is included on the rota and maintains a ‘handson’ approach. Information from the Annual Quality Assurance Assessment submitted by the home earlier this year, and through discussions with the Manager, suggested Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 20 that over 50 of staff have attained at least NVQ Level 2 with some staff having gone to on to NVQ Level 3. This was also confirmed through an interview with the service’s Deputy Manager. One person has been recruited since the last key inspection. Recruitment is now in line with National Minimum Standards and regulations and includes the obtaining of references, a police check, an initial police check, application form and proof of the identity of staff. A requirement at the previous inspection noted that there was no structured induction process. This has been addressed although the member of staff to be inducted last did not have this recorded. This is raised as a requirement in this report. Training of late has included mandatory topics as well as safeguarding training, training in dementia care and continence awareness. The manager has used training with the local authority and training was confirmed through staff interviews. Training records confirmed that further training had been booked for remainder of 2008 and into 2009. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 21 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who live at Thornton Leigh benefit from having an experienced individual managing the service. Residents now have their views taken into account. Residents have their financial interests safeguarded. The health and safety of residents is not fully promoted. EVIDENCE: Mrs Valerie Baker manages the home. She has been the Manager for a number of years and was formally a nurse tutor and holds a nursing qualification. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 22 A Quality assurance system is in place in the form of questionnaires issued to relatives. These were sent out earlier in 2008 with all being returned with positive comments. The questionnaire covers issues such as: presentation of residents, environment, health, activities in the home, staff approach to visitors, comfort of residents, attitude of staff, numbers of staff, respect shown towards residents, availability of senior staff, complaints and privacy given to residents when receiving visitors. There is evidence that residents have now been consulted in respect of food and activities on a monthly basis and there was evidence of resident’s meetings. The service has responded to requirements from the previous inspection with all being met. The service is not responsible for the management of monies yet only has been dealing for one person and this involves liaising with the power of attorney for this person. Families deal with any other monies yet the service has a role in storing monies and recording transactions. All monies are securely stored and are stored individually. Records indicating any transactions as well as receipts accompany them. A statement has been devised outlining arrangements for the dealing with monies and outlines the degree of independence afforded to those who use the service in respect of finances. Training in health and safety topics were confirmed by staff and through training records. In respect of the building, low surface temperature radiators are in use and there was evidence of fire extinguishers being tested on an annual basis. Fire alarms are tested weekly and emergency lighting tested monthly. No fire drills have been undertaken since 2007. This is raised as a requirement in this report. Water temperatures are tested, a gas and electricity certificate is in place confirming the safety of these systems and portable appliances were tested in 2008. Accidents are recorded and in those cases where there are accidents occurring frequently to one person, the care plan indicates actions to minimise these. A certificate of employers liability is in place as well as a certificate of registration is on display. The building was noted to be secure at all times over three entrances and these were secure at all times during the visit. Information in respect of substances hazardous to health is in place. Aids and adaptations are regularly serviced and evidence was available to suggest this. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 23 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 X 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 24 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. Standard OP30 Regulation 18 Requirement Timescale for action 30/11/08 2. OP38 23 The service must ensure that staff inductions are recorded so that there is evidence that those who use the service are benefiting from receiving support form staff that are aware of the role that they have. The service must ensure that fire 30/11/08 drills are held every six months to ensure that the health and safety of all is promoted 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 OP8 OP18 Good Practice Recommendations The service should maintain separate records outlining health appointments attended by those who use the service for ease of reference for staff The service should reinforce the whistle blowing procedure to all staff to ensure that those who use the service are fully protected. Thornton Leigh Care Home DS0000021485.V372807.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Merseyside and Cheshire Local office 3rd Floor, Unit 1 Tustin Court Port Way Preston PR 2YQ 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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