Care Home: Thurleston Residential Home

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What the care home does well The home has good assessment and admission procedures in place and this enables them to develop care plans that reflect people’s health and personal care needs. All records required throughout the inspection were available and maintained in good order. The home is clean and comfortable, visitors tell us that they are made welcome and the managers and care staff are competent, friendly and approachable. The resignation of the previous manager was well managed so that there was an appropriate handover period and smooth transition. What has improved since the last inspection? The home has continued to sustain and build on the improvements we identified at our last key inspection, particularly in the area of medication. They have also increased the activities on offer and begun a phasedThurleston Residential HomeDS0000060474.V378214.R01.S.docVersion 5.2programme of building works to improve the physical environment of the home. What the care home could do better: The manager demonstrated that they have a clear sense of what the home does well and where they need to improve. In particular they confirmed that they would continue to focus on the development of appropriate individual and group activities, the recruitment of a suitable bank of relief staff and the ongoing development of a comprehensive quality control system that includes opportunities for residents to contribute their views. Key inspection report CARE HOMES FOR OLDER PEOPLE Thurleston Residential Home Whitton Park Thurleston Lane Ipswich Suffolk IP1 6TJ Lead Inspector Tina Burns Key Unannounced Inspection 26th October 2009 09:20 DS0000060474.V378214.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thurleston Residential Home Address Whitton Park Thurleston Lane Ipswich Suffolk IP1 6TJ 01473 240325 F/P 01473 240325 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) Guyton Care Homes Ltd Manager post vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 One named person under the age of 65 as detailed in the application for variation dated 2nd February 2006. 17th October 2008 Date of last inspection Brief Description of the Service: Thurleston Residential Home is registered as a care home for older people. The home can accommodate up to a maximum of 24 service users. Guyton Care Home Ltd, with Mr Balaratnam as the Responsible Individual, owns the home. The home is located to the north east of Ipswich about three miles from the town centre. The easiest approach is from the Norwich Road and Whitton Church Lane areas. The home was first registered in July 1996. It is a single storey building located in parkland, some of which is lawned and includes shrubs and ornamental trees. Some of the rooms look over adjacent fields, others over the grounds. The whole setting is tranquil and pleasant. There is parking at the front of the home. The original bungalow has been developed with the addition of ten bedrooms. The building is of wooden design built on stilts and incorporating beamed walls and ceilings. The main lounge and dining areas are located within the original bungalow and another lounge is situated in the new part of the home. The current range of fees, as at this inspection were said to be £362.00 to £460.00 per week. Transport, hairdressing, chiropody, newspapers, private telephone, toiletries other than basic toiletries which are brought for by the home and the services of a therapist, an Occupational Therapists and a physiotherapist are an extra cost. Thurleston Residential Home DS0000060474.V378214.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 two star. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. The inspection process included a tour of the premises and examination of a wide range of documents and records including three residents care plans and three staff files. We also observed activity at the home and spoke with several residents, visitors and care workers throughout the course of the day. Information has also been gathered from the homes Annual Quality Assurance Assessment (AQQA) and survey forms completed by nine residents, eight care workers and four health and social care professionals. The manager and deputy manager were on duty at the time of our visit and fully contributed to the inspection. What the service does well: The home has good assessment and admission procedures in place and this enables them to develop care plans that reflect people’s health and personal care needs. All records required throughout the inspection were available and maintained in good order. The home is clean and comfortable, visitors tell us that they are made welcome and the managers and care staff are competent, friendly and approachable. The resignation of the previous manager was well managed so that there was an appropriate handover period and smooth transition. What has improved since the last inspection? The home has continued to sustain and build on the improvements we identified at our last key inspection, particularly in the area of medication. They have also increased the activities on offer and begun a phased Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.2 Page 6 programme of building works to improve the physical environment of the home. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6. People using the service experience good quality outcomes in this area. Prospective residents can expect to have the information they need to decide whether the home can meet their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home had a Statement of Purpose and Service User Guide displayed in the entrance to the home. Both documents had been updated to reflect the fact that the management of the home had changed since our last inspection and the Commission of Social Care Inspection had been replaced by the Care Quality Commission. There was also a wide range of other information displayed including the homes certificate of registration and public liability insurance certificate, health and safety, fire procedures, complaints and Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 9 concerns, menu’s, programmed activities and leaflets about help, advice advocacy. The resident’s records we examined evidenced that thorough pre-admission assessments are undertaken before a prospective resident moves into the home. We could see that the individual concerned, and where appropriate their relatives and any key professionals, are fully consulted through out the admission and settling in process. One relative told us “We were very apprehensive, particularly as they are rated as a one star home, but they’ve been very good”. They went on to tell us how impressed they were with the support and assistance given by everyone at the home since their admission, particularly the manager who had ensured that they were available to greet them personally on their arrival and spoken with them regularly since. The assessments we looked at included clear information about the individual’s needs and the support they required. Areas covered included; personal care and physical well being, communication and sensory needs, mobility and dexterity, medical history and medication, mental health and cognition, diet and weight. The information provided in the assessments were detailed enough to provide a good basis for a care plan. The home does not provide intermediate care. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People using the service experience good quality outcomes in this area. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at the care plans of three residents. They had been developed in consultation with the people concerned and included clear information about their individual needs, preferences and requirements. There was also good evidence that the plans are regularly reviewed and updated as needs or preferences change. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 11 The areas covered in the care plans we looked at included; personal hygiene, mobilisation, socialising, medication, eating and drinking, communication, continence, phobias and fears, special needs and sleeping. The manager advised us that they were in the process of developing the format of care plans so that they were more comprehensive and provided more detail. People we spoke with confirmed that they were satisfied with the care and support they received at the home. Comments included; “I must admit, they look after me well”, “You can’t fault them” and “They take great care”. Out of the nine surveys returned to us by people that use the service six said that they always receive the care and support they need and three said that they usually receive the care and support they need. Seven said that they always receive the medical support they need and two said usually. Four out of four people that completed surveys for health and social care professionals said that people’s social and health care needs are always appropriately monitored reviewed and met by the service. One of them told us; “Responds promptly to resident’s health needs. Vast improvement over past fifteen months. Excellent communication and working relationships between staff and community nurses”. Records of contact with resident’s GP’s or other health professionals were maintained together with the outcome of appointments. There was also good evidence that the home keeps relatives appropriately informed about resident’s health care matters. The new deputy manager had been delegated the task of ensuring that the homes medication policies and procedures were safe and reflected current guidance and legislation. They talked to us about the procedures in place and demonstrated that they were knowledgeable in this area. We found that the procedures in place for the storage, administration and handling of medication were safe and appropriate. Senior staff at the home are responsible for administering medication and have undertaken appropriate training. One of them was observed administering lunch time medication safely and appropriately. The home used a monitored dosage system and medication was removed from the blister pack directly into a small pot which was given to the resident. The Medication Administration Records (MAR charts) that we looked at had been appropriately completed, there were no gaps identified and staff administering the medication had signed with their initials. There was also appropriate use of codes, for example to identify if medication had been refused or not taken for any reason. Observations were that staff interacted positively with residents and were polite and respectful at all times. Residents spoke highly of care staff and confirmed that their privacy and dignity was respected. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People using the service experience good quality outcomes in this area. People who use this service can expect to maintain contact with their friends and family and enjoy a life style that matches their expectations. Further more they can expect to enjoy a healthy and nutritious diet. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People we spoke with and observations made during our visit confirmed that resident’s friends and families are made welcome at the home. People were seen coming and going throughout the duration of the inspection and visitors we met spoke highly of the home. There was a warm and comfortable atmosphere; Residents, staff and visitors were observed chatting happily amongst themselves, sharing news and enjoying light hearted banter. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 13 As well as promoting family involvement the home also provided information on advocacy services and leaflets for these were displayed in the entrance to the home. The AQAA, completed by the previous manager, tells us that there is “A new and improved activities programme providing a good variety of leisure and social activities”. Regular programmed activities included alternative therapy, armchair exercises, bingo, jigsaws and board games. Planned events have included a Hawaiian evening, a Halloween themed meal and a bonfire party. Outside entertainers have also provided some old time music hall entertainment and future plans include “Jack and the beanstalk”, and “roll out the barrel!”. The manager advised that they have struggled to get residents interested in a structured programme of activities as many of them prefer to spend their time in the privacy of their rooms. However, it is their intention to focus on further developments in this area and they intend, with the support of the new deputy manager, to fully consult residents and relatives about a suitable programme of one to one and group based activities. People we spoke with during the inspection confirmed that activities were available at times but they generally preferred to occupy themselves. One person told us that they like to take a daily walk around the grounds, weather permitting, and another told us that they went to church regularly and enjoyed quite an active lifestyle. Several people told us that they mostly went out with the assistance of their families. The bedrooms we saw were personalised with peoples own belongings such as small items of furniture, pictures and photographs and equipment such as televisions and radios. People told us that they were able to maintain control about the time they get up and go to bed and when they want to bathe. Several of them also enjoyed having a daily newspaper of their choice delivered. Out of the nine residents that completed surveys two told us that there were always activities available to take part in if they wanted to, two said that there were usually activities, four said that there were sometimes activities and one declined to answer. On the morning of our inspection the home had arranged for a retailer to come to the home with a range of clothes for sale. These were displayed in the small lounge for any interested residents. The home had a four week rolling menu in place. The range of meals looked varied and well balanced and people were asked to select from a choice of two options. On the day of inspection the lunch time menu was chicken casserole, mashed potato and vegetables or corn beef hash and baked beans. The choice Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 14 of desserts was lemon sponge and custard or fruit mousse. We were told that residents were able to have their meals in the dining room or in the privacy of their room but most of them used the dining room. We found the tables at lunch time were nicely laid and there was a warm and congenial atmosphere. Comments we received from residents about the food included; “They are good, they are nice meals”, “I can’t find fault with the meals” and “The cook we’ve got here is very, very good”. Out of the nine surveys we received that were completed by residents six said that they always liked the meals, two said that they usually liked the meals and one said that they never liked the meals. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience good quality outcomes in this area. People who use this service can expect their complaints to be listened to, taken seriously and acted upon. Further more they can expect to be protected from abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The homes complaints procedure was on display in the entrance to the home and included in the Statement of Purpose and Service User Guide. It was clearly detailed and included relevant contact details and information about the different stages of the complaints process. People that completed surveys told us that they knew how to make a complaint. They also told us that they knew who to speak to if they were not happy. People we spoke with during our visit confirmed that they feel staff are approachable and they are able to raise concerns and express their views. They particularly praised the manager for her open door policy and it was Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 16 clearly evident throughout the day that staff, residents and relatives felt able to talk openly with her about a wide range of matters. Information provided in the AQAA and discussion with the manager confirmed that the home had received nine formal complaints since the previous inspection. Although none of these had been made since the current manager has been in post it was evident from the records held that they had been taken seriously and responded to appropriately. The manager felt that her policy of ensuring that she speaks with all residents daily enables issues or concerns to be dealt with promptly and before they become complaints. Staff we spoke with had undertaken Safeguarding Adults Training and the manager advised that the home had adopted the local authority inter agency policy and procedures for safeguarding adults. The commission is not aware of any safeguarding investigations related to this home in the previous twelve months. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26. People using the service experience good quality outcomes in this area. People who use this service can expect to live in a safe, clean and comfortable environment. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Thurleston Residential Home is a single storey property; all bedrooms are single, ten have en-suite WC’s with wash basins and the remaining fourteen have a wash hand basin in the bedroom. In addition there are two assisted bathrooms and separate toilets located throughout the home. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 18 Observations made during the inspection, information provided in the AQAA and discussion with the manager confirmed that the home has an ongoing decorating and maintenance programme. The manager also advised us that they are in phase one of an improvement programme that includes the building of a two storey extension, the building of a new porch and seating area to the entrance of the home, additional car parking and full security lighting, provision of a wet room and staff room and provision of a new clinical waste compound. Phase two has not yet been scheduled but will include a full refurbishment of the original building. The décor and furnishings were domestic in style and although in places a little dated they were of a good standard and well maintained. Bedrooms we saw were personalised with residents own belongings and people we spoke with said that they could chose whether to spend their time in the privacy of their own room or one of the communal lounges. The communal areas comprised of a dining room and lounge at the front of the building and a smaller lounge at the rear of the property. At the time of inspection all areas seen were tidy, safe and clean and there were no unpleasant odours. Eight out of the nine residents surveys returned said that the home was always fresh and clean and one said it was usually fresh and clean. Observations on the day of our visit and information provided in the AQAA confirmed that the home has appropriate infection control procedures in place. There were adequate laundry facilities and staff were provided with disposable gloves, aprons and hand wash. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. People who use this service can expect to be supported by staff with the skills and knowledge to meet their needs. They can also be assured that they are safeguarded by thorough and robust recruitment procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Three staff recruitment records were examined and included all documentation required including photographs, evidence of ID, CRB checks, application forms, references and health checks. The manager explained they have reviewed and updated the recruitment process to ensure that checks are rigorous, references are verified and face to face interviews are a thorough and effective means of identifying the suitability of applicants. Feedback from staff and records seen confirmed that new carers undertake an induction programme that meets the Skills for Care induction standards. Staff training covers areas such as safeguarding adults, health and safety, fire safety, food hygiene, emergency first aid and manual handling. Information provided in the AQAA and discussion with the manager confirmed that sixteen Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 20 out of the homes seventeen permanent care workers have relevant National Vocational Qualifications. Eight out of eight care staff that completed surveys told us that they are provided with training that is relevant to their work, helps them to understand the needs of people that use the service, keeps them up to date and gives them enough knowledge about medication and healthcare. Six out of nine residents that completed surveys said that they always received the care and support they need and three said that they usually received the care and support they need. Five said that staff are always available when they need them and four said that they are usually available when they need them. Feedback from residents and staff tells us that with the exception of some episodes of sickness the home is appropriately staffed to meet resident’s needs. The manager acknowledged that sickness absence sometimes impacts on staffing levels so their intention is to recruit a bank of relief staff to cover shifts at short notice. In the mean time they advised that they and their deputy are supernumerary and step in ‘the breach’ when necessary. This enables them to minimise the use of agency staff that are unfamiliar with the residents and gives them the opportunity to get to know staff and residents well and provide ‘on the job’ supervision. On the day of our visit our observations were that residents were assisted by staff in an appropriate and timely manner. Comments we received from residents and visitors included; “The carers here are nice people. They always come and say hello”, “They are all good. I haven’t found any fault with them” and “I must admit they look after me well”. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38. People using the service experience good quality outcomes in this area. People who use this service can expect to benefit from a well managed home that is run in the best interests of the residents. They can also expect their health, safety and welfare to be promoted and protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The previous manager of the home had their registered manager’s application approved in July 2009 but resigned soon after and left the home in August 2009. The new manager reported that they had started approximately a week Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 22 before the previous manager had left and they had benefited from a planned handover. The new manager advised that they were subject to a three month probation period after which it was their intention to submit a registered manager’s application to the commission. They have since made an appointment with us to start the Criminal Record Bureau Check process. The manager and the deputy manager were on duty on the day of our visit. They were very receptive to the inspection process, welcomed discussions about the running of the home and provided all the information we asked for promptly and co-operatively. Observations made during the inspection and feedback from staff, residents and visitors confirmed that the manager provides strong leadership and is approachable and respected. The AQQA completed by the previous manager tells us that the home undertakes an annual resident’s satisfaction review. It also tells us that resident’s meetings take place so that people are able to contribute to decisions about the running of the home. The current manager advised that they were in the process of establishing a comprehensive quality control system that would continue to include processes such as customer surveys and residents meetings. Discussion with the manager, observations made during our visit and feedback from the local authority care quality monitoring team confirmed that the manager has a clear understanding of what the home does well and where and how they need to improve. We were pleased to find that improvements identified at the last inspection, particularly around the management of medication, had been sustained. The home prefers that residents are assisted with their finances by a representative or family member. However it does hold small amounts of personal money for safe keeping. Records of all monies held are maintained in good order with receipts to provide a good audit trail of income and expenditure. Records seen and feedback from staff evidenced that staff are appropriately supervised. Eight out of eight care workers that completed surveys told us that their line manager gives them enough support and meets with them regularly to discuss their performance. All records required were made available during the inspection and were maintained up to date and in good order. Records referenced during the inspection included staff recruitment records, staff training and development records, residents care plans and pre admission records, medication records, and health and safety and maintenance records. Discussion with the manager, observations made during a tour of the premises and records seen confirmed that routine maintenance and health and safety Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 23 tests are carried out, for example fire alarm and fire equipment tests, water temperature checks and manual handling equipment checks. The manager was also in the process of completing an emergency contingency file that would include personal emergency evacuation plans for all residents. Training records confirmed that staff undertake appropriate health and safety training such as infection control, food safety, manual handling, fire safety, first aid and control of substances hazardous to health (COSHH). Procedures for reporting accidents and incidents were also in place. Since our previous inspection the home has had a fire inspection and a food hygiene inspection and all matters raised have been addressed. The council awarded them a four star rating for good food safety management and a high standard of compliance with food safety legislation. Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 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 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thurleston Residential Home DS0000060474.V378214.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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