Care Home: Thurnscoe Hall Nursing Home

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What the care home does well The management of the home was based on openness and respect. The manager had a good knowledge of the needs of people and was committed to providing a good quality service. Generally, the administration showed there were systems in place to manage the health, safety and welfare of people and staff.There was an experienced, trained and stable staff team that were in sufficient numbers to meet the needs of people living there. When we spoke with people they spoke highly of the staff team saying, "they`re kind and generous" and "staff are very kind and caring, infinite patience". The admission process was well managed. People said they received enough information about the home and they had their needs assessed before they moved in. People praised the care and medical support they received. People were assisted to make choices, decisions about their daily life and social activities. Mealtimes were a relaxed and leisurely time for people and people liked the meals they were served. People were able to express their concerns and had access to a complaints procedure. There were adult safeguarding policies and procedures in place that promoted the protection of people from harm. What has improved since the last inspection? All but one of the toilet and bathroom doors were closing more easily, so that the lock on the door can be used to maintain peoples` privacy and dignity. In addition, the majority of window restrictors had been repaired/replaced. Medication being received was being checked against the medication administration record to make sure there were no discrepancies. Also, another member of staff, to reduce the risk of errors, was verifying handwritten entries made on the medication administration record. Since the last visit the owner and manager had carried out maintenance and further refurbishment to improve the environment for people. This included repairing the conservatory roof, replacing the flooring in the bathroom and redecorating corridor areas. Relative and resident meetings had started. This assisted gave people and their representatives the opportunity to express what they see as improvements within the service. What the care home could do better: Fully complete records that are kept for people, to demonstrate their health care needs are being monitored as identified in the plan of care, for example, nutritional and moving and handling risk assessments.Provide written evidence of gaps in employment and check with the person about their employment history. CARE HOMES FOR OLDER PEOPLE Thurnscoe Hall Nursing Home High Street Thurnscoe Rotherham South Yorkshire S63 0ST Lead Inspector Jayne White Key Unannounced Inspection 5th November 2008 8:45 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 Thurnscoe Hall Nursing Home DS0000006492.V373018.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. Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thurnscoe Hall Nursing Home Address High Street Thurnscoe Rotherham South Yorkshire S63 0ST 01709 890086 01709 894363 none www.thurnscoehall.co.uk Mr Rajendra Prasad 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) Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 24 16th November 2007 2. Date of last inspection Brief Description of the Service: Thurnscoe Hall is a 17th Century stone built Grade 2 listed building with a purpose built extension and conservatory. The home is registered to provide nursing, personal care and accommodation to 24 older people. The home stands in its own extensive gardens with mature trees and shrubs and has a sitting area for people and their families. Accommodation is on three floors. A passenger lift is in use to access them. All bedrooms are for single use. There is a car park to the side of the building. The home is situated in Thurnscoe village, ten miles from Barnsley town centre, close to the A635 Barnsley to Doncaster Road, with easy access by bus or train. The home is within walking distance of all local amenities, including, supermarkets, chemist, optician, post office, hairdressers, community centre, bowling green, pubs, clubs, the village church and health centre. Information about the home, including the service user guide is available in the entrance hall. This includes the most current Commission for Social Care Inspection (CSCI) report about the service. The manager said the fees ranged from £351.50 to £393.43. If nursing care is required this contribution is free of charge to people. Additional charges are made for hairdressing, private chiropody, individual toiletries, papers and magazines and spending money on day trips. Thurnscoe Hall Nursing Home DS0000006492.V373018.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 star. This means that the people who use this service experience good quality outcomes. We visited the home on 5 November 2008 between the hours of 8:45 and 17:15 without giving them any notice. As part of the visit we took into account other information received by CSCI about the service since the last inspection. This included: • • Information contained in notifications from the home about any deaths, illnesses and other events, which affected the health and well being of people living there. An Annual Quality Assurance Assessment (AQAA). An AQAA is a document completed by providers. It gives them the opportunity to tell the CSCI how well they think they are meeting the needs of people using their service. Ten surveys that had been returned by people living at the home, which told us their experiences of the service. Four surveys received from staff, which told us what they thought about the care and support provided, the way the home is run and what they thought the home did well and what it could do better. • • During the visit we spoke with people that lived there and their representatives. We also spoke with staff, the manager, looked round parts of the building and read some records. We would like to thank the people and their representatives, staff and manager for their time and co-operation throughout the inspection process. CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they would have no direct affect on the outcome of the service provided for people. What the service does well: The management of the home was based on openness and respect. The manager had a good knowledge of the needs of people and was committed to providing a good quality service. Generally, the administration showed there were systems in place to manage the health, safety and welfare of people and staff. Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 6 There was an experienced, trained and stable staff team that were in sufficient numbers to meet the needs of people living there. When we spoke with people they spoke highly of the staff team saying, “they’re kind and generous” and “staff are very kind and caring, infinite patience”. The admission process was well managed. People said they received enough information about the home and they had their needs assessed before they moved in. People praised the care and medical support they received. People were assisted to make choices, decisions about their daily life and social activities. Mealtimes were a relaxed and leisurely time for people and people liked the meals they were served. People were able to express their concerns and had access to a complaints procedure. There were adult safeguarding policies and procedures in place that promoted the protection of people from harm. What has improved since the last inspection? What they could do better: Fully complete records that are kept for people, to demonstrate their health care needs are being monitored as identified in the plan of care, for example, nutritional and moving and handling risk assessments. Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 7 Provide written evidence of gaps in employment and check with the person about their employment history. 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. Thurnscoe Hall Nursing Home DS0000006492.V373018.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 Thurnscoe Hall Nursing Home DS0000006492.V373018.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): The outcome for standard 3 was inspected. The home did not provide an intermediate care service, standard 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People received enough information they needed to choose a home and had their needs assessed before they moved in. This meant both the home and the person could be sure their needs would be met. EVIDENCE: We looked at the files of three people. They all had an assessment that had been completed by the service. The information was basic, particularly in respect of people’s mental capacity. One of the files had an assessment from the placing care manager. However, overall, a good plan of care had been put together from the information. Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 10 All people, via the survey said that they had received enough information about the home before making a decision to move there. They commented, “family did it on my behalf” and “I stayed for short visits before becoming permanent”. When we spoke to people, they all said family had chosen the home. When we spoke to some of their representatives they confirmed this. They said they came and looked round before they made their decision. They told us an assessment was carried out to say the person they were representing could stay there. Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 11 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): The outcomes for standards 7, 8, 9 & 10 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people received reflected what assistance they needed. Overall, people were treated with respect, dignity and privacy. EVIDENCE: On the whole, people told us they received the care and medical support that they needed. When we spoke with them they said that they were well cared for and they were happy with the way that staff looked after them and respected their dignity. When we looked round the building, all but one of the toilet and bathroom areas had a working lock. The one that didn’t work was brought to the attention of the manager to address and the previous requirement removed. Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 12 When we observed staff working there was clear and respectful communication between people and staff and staff treated people in a kind manner. However, there was an occasion when staff were speaking between themselves and not including people in their conversation, which would add to peoples’ quality of day-to-day life. We made the manager aware of this, so that she could address it with staff. People were immaculately dressed, with no food spillages on their clothes. Their hair and nails were clean. We looked at three care plans to confirm what people were telling us. The plans contained some good information. However, there were some gaps in the information, which did not always make it clear to staff, the care to be provided. For example, in two of the files a nutritional risk assessment had not been completed. This was crucial in one instance, because of the medical condition of the person. This contradicted information in the AQAA, which told us nutritional screening was carried out on everyone admitted to the service. In addition, in one file, a moving and handling assessment had not been fully completed and in another the moving and handling assessment contained information that was incorrect when staff moved the person. The entries in the daily report, on the whole, contained good detail, including information about pressure areas, which had been identified in the plan of care. There was an instance where there was no information to confirm blood sugars were being taken and monitored as identified in the plan of care. This was brought to the attention of the nurse in charge, to action. Qualified nursing staff administered medication. On the whole, medication was being stored securely. Where it wasn’t being stored as required, action was being taken to address this. We looked at the recording, administration and storage of medication on a sample basis. Records were kept of medication being received. Hand written entries that had been made on the medication administration record had two signatures. This helps in verifying the information is correct, to reduce any errors when administering that medication. We saw that when people were given their medication it was done in a respectful and dignified way. A drink was available to assist people take their medication. People were prompted and encouraged to take their medication where this was necessary. Thurnscoe Hall Nursing Home DS0000006492.V373018.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): The outcomes for 12, 13, 14 & 15 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were assisted to make choices, decisions about their daily life and social activities. EVIDENCE: When we entered the home there was a pleasant ambience in the communal areas. In the surveys that were returned, two said the home always arranged activities they could take part in, one said usually and seven said sometimes. Two people commented, “I like to read and watch TV and go for little walks” and “staff try hard, but often residents are reluctant to participate”. When we spoke to people they described how they chose how to spend their day. They said they could choose what time to get up and go to bed within reason, accepting the constraints as part of group living. They said they spent Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 14 time talking with other people in the lounges, reading and doing crosswords and word searches. When we looked at how the home engaged with people to determine the quality of the service, the manager told us she had commenced resident and relative meetings. When we looked at these it told us, people and their representatives were consulted about what events they wished to take part in. People said their family and friends could visit “at any time”. One person said, “my wife visits regular – she comes when she likes”. This means they are able to maintain important personal and family relationships. We saw a number of visitors. When we spoke to them they confirmed they could visit at any time and that they were made to feel welcome by being offered a drink and staff being friendly. On the whole, people said they liked the meals. When we spoke to people they said they enjoyed their meals and had enough to eat. One person’s representative said, “the meals look and smell beautiful”. We saw the breakfast and lunchtime meals being served. The dining room was welcoming, being bright and clean. There was no rush to the mealtime and people were given sufficient time to eat. Staff were patient and helpful and allowed people time to finish their meal comfortably. Breakfast was a variety of cereals and toast and this was served to people as they got up. There were some people able to pour themselves a drink and butter their toast, but staff did this for them. Providing teapots and condiments for people would enable people to maintain control over aspects of their life where they were able. Care staff were sensitive to those people who found it difficult to eat their meal themselves and needed assistance. They helped the person at their pace, making them feel comfortable and unhurried. Thurnscoe Hall Nursing Home DS0000006492.V373018.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): The outcomes for standards 16 & 18 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were able to express their concerns and had access to a complaints procedure. There were adult safeguarding policies and procedures in place that promoted the protection of people from harm. EVIDENCE: People they said they were highly satisfied with the care they received and felt safe. They said they would speak up if there was something they weren’t happy about. This indicated there was an open culture that allowed people to express their views and concerns in a safe and understanding environment. People said they had no complaints or grumbles and felt people would listen if they did have anything to say. Comments people made included, “I feel safe all the time” and “if I’m unhappy I’d tell Michael, my number one carer”. People could access the complaints procedure because it was displayed on the notice board in the entrance hall for them should they wish to make a complaint. It was clearly written, easy to understand and explained what the procedure was and how long the process would take. Since the last inspection, no complaints have been to the CSCI. One complaint had been raised with the home and social services. There was a record of the Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 16 complaint. We spoke with the manager about maintaining objectivity when investigating complaints and not taking the complaint personally, because this is what the record indicated. In addition, to be clear and document about what methods they had used to investigate the complaint. There were adult safeguarding policies and procedures in place that promoted the protection of people from harm or abuse. The manager had attended an information day on the reviewed South Yorkshire adult safeguarding procedures. She had updated those procedures with information from each authority about how to make an alert should one be made. Thurnscoe Hall Nursing Home DS0000006492.V373018.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): The outcomes for standards 19 & 26 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The living environment was clean, well maintained and a comfortable environment for people to live. EVIDENCE: People said that they were happy with their living environment. People said they had a comfortable bedroom, which some people had personalised with pieces of their own furniture and possessions. Since the last visit the owner and manager had carried out maintenance and further refurbishment to improve the environment for people. This included repairing the conservatory roof, replacing the flooring in the bathroom and redecorating corridor areas. Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 18 When we looked round the home it was well lit and smelt fresh. There were a number of sitting areas and spaces for people to eat. There were sufficient toilets for people that were appropriately located and easily accessible. We brought to the owner’s attention, that some toilet seats needed replacing as the seats were worn and did not look pleasant. Also, having paper towels available in bedroom areas would be good practice in controlling the spread of infection. The gardens were tidy with mature trees and shrubs. Thurnscoe Hall Nursing Home DS0000006492.V373018.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): The outcome for standards 27, 28, 29 & 30 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was an experienced, trained and stable staff team that were in sufficient numbers to meet the needs of people living there. EVIDENCE: Generally, when we spoke to people they had confidence in the staff that cared for them and that on the whole staff were usually available when they needed them and staff listened and acted on what they said. Their comments included, “they’re kind and generous” and “staff are very kind and caring, infinite patience”. We observed how staff worked during the visit. This told us there were good relationships between staff and people and they responded in a timely way when people needed assistance. There was a nurse was on duty on each shift to assist with the nursing needs of people. In addition to this there were two care assistants on the morning and afternoon shift and one on the night shift. Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 20 The AQAA told us training opportunities were provided. This was confirmed by staff when we spoke with them and looked at their surveys. The AQAA stated nearly all staff had NVQ Level 2, eighty per cent had received training in malnutrition care and assistance with eating and two catering and nine care staff had received training in safe food handling. When we spoke with staff and looked at their surveys, this told us their induction covered everything they needed to know when they started, that they are given training relevant to their role, helps them understand and meet the needs of people they care for and keeps them up to date with new ways of working. Staff told us the training they had completed included, fire risk assessment, medication, care planning, adult safeguarding, nutrition and palliative care. They said they received support and guidance appropriate to what they needed. One member of staff commented, “we’re a good team and work well together”. The AQAA stated there was a recruitment policy in place. We looked at two staff files on a sample basis to confirm this was followed. The file told us some aspects of a thorough recruitment procedure was followed. This included criminal record bureau disclosures and written references. One of the files identified there were gaps in employment and the career history didn’t identify a previous place of work. There was no written evidence that this had been discussed with the person. Thurnscoe Hall Nursing Home DS0000006492.V373018.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): The outcomes for standards 31, 33, 35 & 39 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management of the home was based on openness and respect. Generally, the administration showed there were systems in place to manage the health, safety and welfare of people and staff. EVIDENCE: People were pleased with the service they received and spoke highly of the owner, manager and staff. The manager had many years experience within the caring profession. She had a good knowledge of the needs of people and was committed to providing a good quality service. Her direction and leadership promoted a relaxed and friendly atmosphere. However, she has been in post a Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 22 number of years and is not registered with the CSCI. The manager states the owner is aware of this. The registration and enforcement team have been notified of this to achieve compliance with having a registered manager. People and their advocates expressed satisfaction with the service. The manager had implemented a quality audit, with the results displayed in the entrance hall. The audit report identified there were no serious problems, with good outcomes being the refurbishment and social functions. Resident and relative meetings have commenced in the last 12 months. The most recent one had focused on the preferred choices for social events for people. This shows the people and their relatives have their ideas were listened to. The manager said the owner visits the home frequently but does not complete reports of his visits. This does not provide CSCI with any information of his opinion of the quality of the service and the action they are taking to make improvements. People were encouraged to maintain control over their own finances unless they did not want to or lacked capacity. When we spoke to people they said ‘the home looked after their monies, but they could get it at any time’. When we looked round the building fire exits had been kept clear, which should make it easy for people and staff to leave the building should there be a fire. The fire risk assessment had last been reviewed in January 2008. It was brought to the manager’s attention. She said staff had been on a fire risk assessment course and the intention was they were going to do this. However, that training had been in October 2007. She was told to ensure this was acted on to identify and confirm the current arrangements are still satisfactory. Action had been taken to repair and replace the majority of window restrictors to keep people safe. Those that had been missed were identified to the manager, so they could be replaced. The AQAA stated servicing and maintenance was in place for electrical circuits, portable electrical appliances, the lift, hoists, fire detection and fire fighting equipment, emergency lighting, emergency call equipment, the heating and gas. The contract on file for disposal of soiled waste expired on 31 March 2008. The manager was told a copy of the new contract was needed to confirm they did have a contract. Thurnscoe Hall Nursing Home DS0000006492.V373018.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Thurnscoe Hall Nursing Home DS0000006492.V373018.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 OP7 OP8 Regulation 15 (1) 17 (2) Requirement Timescale for action 06/11/08 2. OP7 15 (1) 3. OP29 19 (1) (b) The plan of care must contain a nutritional risk assessment, to identify how people’s nutrition and dietary requirements are to be met. People’s moving and handling 05/12/08 assessment must be fully completed and up to date so that people know how to move people and they do it safely. So that people can be assured 05/12/08 they are protected, staff files must contain a full employment history, together with a satisfactory written explanation of any gaps in employment. 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 OP31 Good Practice Recommendations The manager should be registered with the CSCI. This is so that the CSCI can make a judgement that she has the DS0000006492.V373018.R01.S.doc Version 5.2 Page 25 Thurnscoe Hall Nursing Home 2. OP33 qualifications, skills and experience necessary for managing a care home and is physically and mentally fit to do so. A written report of the owner’s monthly visit should be completed and forwarded to the CSCI. This provides CSCI with information of their opinion on the quality of care the service provides. Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thurnscoe Hall Nursing Home DS0000006492.V373018.R01.S.doc Version 5.2 Page 27 - 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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