Inspection on 21/04/09 for Thames Clinic

This is the latest available inspection report for this service, carried out on 21st April 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

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Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Thames Clinic 40-46 Cromwell Road Kingston Upon Thames Surrey KT2 6RN Lead Inspector Michael Williams Unannounced Inspection 21st April 2009 10:00 Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 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 home adults 18-65 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. Thames Clinic DS0000072398.V374966.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 Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thames Clinic Address 40-46 Cromwell Road Kingston Upon Thames Surrey KT2 6RN 0845 241 3401 0845 241 3402 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) Alcohol & Drug Detox Limited No registered manager Care Home 6 Category(ies) of Past or present alcohol dependence (6), Past or registration, with number present drug dependence (6) of places Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category/ies of service only: Care Home providing nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Past or present drug problem - Code D Past or present alcohol problem - Code A 2. The maximum number of service users who can be accommodated is: 6 Date of last inspection N/A Brief Description of the Service: Thames Clinic is run by Alcohol & Drug Detox Limited, a provider of services for individuals experiencing substance misuse problems. Mr Gavin Cooper is registered as the Responsible Individual for the purposes of the Care Standards Act 2000. The Thames Clinic is located on the first floor above other drug and alcohol services but it has no connection with these other units other than to share the same landlord. There is a separate, secure entrance accessed from the street via a steep flight of stairs (which make this home unsuitable for people with mobility problems). The accommodation is modern and fairly spacious with six en-suite single bedrooms. There is an open plan dining/kitchen room, a lounge, an office and a clinic room. There is one communal toilet for the use of visitors and staff and a very small laundry room. Storage space is very limited and there is no visitor/meeting room. There is a communal garden to the rear and side of the property but this will be divided and fenced to give Thames Clinic its own private garden. The home is close to all local amenities including public transport and shops. There is no off road parking for the home. Fees are from £3,000 per week, pro rata and on a sliding, reducing scale for extended residence. Thames Clinic DS0000072398.V374966.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. To monitor all aspects of care the we ‘tracked’ the care provided to a sample number of residents and triangulate the information including the documentation supporting care, the meals provided, the arrangement for medication, records of complaints and accidents. Staff providing care were interviewed, and by interviewing or observing the residents themselves. Questionnaires were also distributed and feedback noted. We also took account of other information including that relating to the initial application for registration which was completed on 4th November 2008. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose and the service user guide both need to be amended and brought up to date so as to provide all the information listed in the regulations and standards. The procedures for auditing medication needs to be strengthened so as to identify errors more readily. Staff records including those dealing with recruitment must be available in the care home for inspection by the Commission unless the service seeks and is granted permission for alternative arrangements for the inspection of these documents. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 6 We noted some environmental concerns including the paucity of storage space. We also noted that some fire doors were not closing fully to their stops and in one instance a wooden wedge was used to wedge open a door; more suitable arrangements for holding door open must be put in place such as magnetic door holders. The Commission will require this new service to conduct provider’s monthly unannounced visits and to report to the owners and to the Commission; these are known as Regulation 26 visits/reports. The home must also ensure that the Commission is advised of any absence of the registered persons, this includes the original and registered manager who has since left the service. There is a new manager who will need to apply for registration without delay. As Thames Clinic is located in ‘rented’ accommodation it must provide evidence, possibly in the form of the contract with the landlord, that this will not inhibit the registered persons from complying with any regulatory requirements or relevant national minimum standards including changes to the structure or use of the premises so as to meet requirements. 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. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 2 and 5: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient information is provided to assist residents in choosing this service and the agreements made with residents ensure their needs can be met. EVIDENCE: To assess this section of the report we visited the service and spoke to residents, staff and manager. We checked the documentation provided to new residents including the statement of purpose and resident guide. We also checked contacts and agreements. We also checked the facilities provided for residents and staff. The home provides a Statement of Purpose and guide that is specific to the individual home and the resident group they care for. It sets out the objectives and philosophy of this specialised service with additional information provided in the resident’s individual Guide or handbook. These document do however need to be updated so as to provide all the information listed in the standards and regulations. The guide details what the prospective residents can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications and experience of staff, how to make a complaint. As this is the first inspection of Thames the guide does not yet contain information about previous inspection findings nor at this early stage does it contain comments and experiences of residents living at the home. All residents are however given a copy of the guide. When requested the service Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 9 can provide a copy of the statement of purpose and guide in a format which will meet the capacity of the resident. Admissions are not made to the home until a full needs assessment has been undertaken and this sometimes but not always includes several agencies including care managers. For people who are self-funding and without a care management assessment, a skilled and experienced member of staff will undertake the pre-admission assessment. Where the assessment has been undertaken through care management arrangements the service insists on receiving a summary of the assessment and a copy of the care plan. We are told that the initial screening of prospective residents is done at the head office with information passed to Thames Clinic and it is rare for a resident to visit the service before being admitted. We are told this is in part because of the nature of the service, it is a ‘detox’ unit where residents are usually in crisis and require urgent medical/nursing support for withdrawal from drugs or alcohol. The manager is well aware of the fact that she must be responsible for admissions and act as ‘gatekeeper’ to avoid inappropriate admissions. We are advised that each resident receives a contract/agreement from head office and this includes details of the, not insubstantial, fees payable. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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): NMS 6 to 10: People using the service good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are being appropriately assessed with relevant care plans in place so they can be assured their needs are known and suitably addressed. EVIDENCE: The key principle of the home is that people using the service, residents are supported to regain control of their lives. Staff are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. People using the service make their own informed decisions and have the right to take risks in their lives. In effect this means that some residents will choose to leave the service quicker than planned for, the service refers to this as ‘discharged against medical advice’. It does however give a clear indication that residents remain in control of their lives and are free to make choices, even unwise ones. Care plans are developed with, and owned by the person using the service. It is based on a full and up to date holistic assessment. It includes reference to equality and diversity and clearly addresses any needs identified in the six strands of diversity which are: gender (including gender identity), age, sexual Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 11 orientation, race, religion or belief, and disability. The plan is person centred and focuses on the individual’s immediate needs in relation to detoxification and wider needs of exploring why addiction is problem in their lives. The plans and assessments, and risk assessments, include a very wide range of information that is important to the person and their treatment. This could be information such as who and what is important to them, how they keep safe, their goals and aspirations, their skills and abilities, and how they make choices in their life. It includes vital information about their health, in particular their drug taking or alcohol consumption and any related health issues. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: NMS 11, 12, 13, 15, 16 and 17: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that Thames Clinic will provide services to meet their social needs. EVIDENCE: Residents spend only a very small number of weeks in the Thames Clinic and the priority is to help residents cope with the physical and emotional symptoms of withdrawing from their addictive substances, drugs or alcohol. The service does not aim to provide a fulfilling lifestyle for residents, instead its aim is for their medical safety whilst withdrawing. Nevertheless as part of the service the staff team work intensively with residents in group and individual counselling sessions to support an improved way of life and begin, where possible, a therapeutic programme that may include moving to a longer term rehabilitation unit. For the short time that residents are in this unit other activity, work or leisure, is suspended during their recovery period in the Clinic. The unit support residents to maintain social links that are positive and will not adversely affect their detox’ programme. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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): NMS 18, 19 and 20: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This nursing service can provide appropriate detoxification support to residents. So residents know their health care needs can be met. EVIDENCE: From our observations, the opinion of a visiting doctor and the residents themselves we assess Thames Clinic as providing a very good ‘Detox’ service. Residents receive effective personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. The statement of purpose sets out the competencies and specialist services the home offers and delivers this effectively through a skilled, trained and knowledgeable staff group that work in a person centred way. Staff are highly aware that the way in which support is given is a key issue for the residents they support. Individual plans clearly record people’s personal and healthcare needs and detail how they will be delivered. These needs might be recorded in their health action plans and these include very detailed information about risks, social medical and behavioural. This home specialises in the short term support of people who have elected to be admitted and ‘detox’ or withdraw, to this end the nursing staff work with the visiting doctors to provide medication regime that will Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 14 ensure the safety of residents and reduce the unpleasant and sometimes very risky side-effect of withdrawal. The residents are encouraged to manage their own healthcare since is it likely many will have neglected their health as part of their addiction. Residents will be temporary patients of local GP practice that has formulated an agreement with the home to provide (private) treatment and prescriptions for detoxification process only. Other medical needs will be referred back to the residents’ own doctors and so they will have access to all NHS healthcare facilities in the local community. Regular appointments are seen as important and there are systems to ensure they are not missed. The home arranges for health professional, in particular the GP, to visit residents at home when necessary for example for medical assessment and review of medication. The home fully respects the rights of people in the area of health care and medication. They recognise and work with the decisions made by the individual regarding any refusal to take medication, or any specific requests about how their healthcare is managed. Staff members, including a nurse on each shift, are very alert to changes in mood, behaviour and general wellbeing and fully understand how they should respond and take action. The home has developed efficient medication policy, procedure and practice guidance. Staff all have access to this written information and understand their role and responsibilities. Quality assurance systems confirm that policy is put into practice. The home strongly promotes independence and those individuals assessed as being able are encouraged and supported to manage their own medication. Medication records are seen as key to the efficient management of health care matters, the home consistently keeps them up to date. The home has a sustained record of full compliance with the administration, safekeeping and disposal of controlled drugs. Care staff have the required accredited training. The homes policies, procedures and guidance support and inform practice. We did however identify the need for the home to be able to audit medication more readily by ensuring each medication chart has details of the amount of tables the home as so that a numerical check can e made at any point in the month. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 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): NMS 23: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that complaints will be listened to but the document to support this needs refinement. EVIDENCE: The home already has in place systems for addressing residents’ concerns including information about the complaints procedures, information about the company and about the Commission. The home also provides feedback questionnaires in order to actively seek residents’ views. We saw a number of these and they were very positive about the service describing it as excellent and very supportive. The home’s policy on protecting adults from abuse, also referred to as ‘safeguarding’ was in place but referred only to in-house investigations. Any suspicion or allegation of abuse must be reported to the local (Kingston) safeguarding team who will assist in deciding what investigation process is to be followed and this may involve the police or the Commission in addition to any other investigations. The home has yet to acquire a copy of the local authority’s guidance on reporting abuse and must do so without delay. All staff should receive training based upon that guidance. No complaints have yet to be recorded by the home but the manager agreed to put in place a record or register of any complaints or allegations. No complaints were made to the Commission during our inspection visit and we have received no critical comments from any other sources. By contrast we have received numerous positive comments about this very specialised service. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 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): NMS 24, 25, 26, 27, 30: People using the service experience good adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We can assure residents that this is safe and comfortable environment but it is not without some limitations. EVIDENCE: This home was registered by the Commission on 4th November 2008 at which time it was assessed as being suitable premises for the service to be provided. It is not without its shortcomings however. There is very little storage space; it is located on 2nd floor of a block so it is inaccessible for people with mobility problems; there is no private meeting room, other than resident’s own bedroom. Based as it is on the second floor access to the small, and as yet undeveloped, garden is via two steep stair cases. Several residents have commented upon their steepness. The garden at present is shared with other tenants and is a weed strewn plot. The manager advises us that it is to be fenced off and developed into a more suitable outdoor area and this may include a vegetable plot. There is a lift but this is through a communal area and not specific for Thames Clinic. We noted on the fire escape route that a bicycle had been chained to the stair railings. This area although used by Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 17 residents of Thames Clinic it is not under the control of the manager – who agreed to request, but presumably not instruct, that the stair well is not used for storage nor blocked in this manner. We are concerned that as tenants this registered service may not be in a position to comply with requirements such as this since such matters are within the control of the landlord and not the registered persons. We will ask for confirmation that the registered person can comply will regulatory requirements including those affecting the use of the building and changes or maintenance of the building. Despite these shortcomings the home is otherwise very pleasant and modern in appearance. Each bedroom has ensuite facilities as well the usual range of furniture such as bed, wardrobe, drawers, table, chair and so forth. Each bedroom has a fire resistant door but some were not closing fully to there stops and so this would allow smoke to enter the room in the event of fire. We also saw a wooden wedge used to hold open a bedroom door and again this would compromise fire safety and a more suitable device like a magnetic door holder would be safer in this situation. The bedrooms have no natural ventilation but do have air conditioning. The unit is protected by entrance gates that are locked and over overlooked by security cameras. The unit, all on one floor, has a lounge, a combined kitchen dining area, a clinic room and office and a very small laundry room. The residents find this a nice home and say it is a very comfortable place to reside in and one that meets their expectations. They told us they feel safe and secure here. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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): NMS 32, 35 and 36: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We can assure residents that the staff team is providing an excellent service. EVIDENCE: The staff team working is this unit is impressive. It include a well qualified and experienced manager, staff trained in (drug and alcohol addiction) counselling, nurses and trained support workers. It is supported by clinic staff to provide clinic supervision for the nurses. Doctors are contracted to provide support and prescribe treatments for the residents. The residents tell us that they are very happy with the support they are getting from staff and this includes one to one counselling and therapeutic group sessions. The manager is putting in place training and supervision schedule for each member of staff an aims to improve training still further but there seems little doubt the current team are doing very good job as judged by the visiting doctor who specialises in care of people with addictions ad who is impressed by the service. The doctor notes that the service is very time limited and will have little impact on the long term needs of his patients but acknowledges that Thames Clinic provides a critical first step, detoxification, towards recovery and Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 19 long term abstinence. The staff also have the skills to help residents to begin to address the many underlying issues that will have lead to the addiction problems. There were some key issues to be resolved and the first was about the protocols for safeguarding adults from abuse. The home has yet to acquire a copy of the local authority’s guidance on reporting abuse and must do so without delay. All staff should receive training based upon that guidance. The second issue is the matter of staff recruitment and in particular the availability of documentation. Recruitment is conducted by head office in Luton. The regulations require the documentation, demonstrating safe recruitment practice and procedures, must be available for inspection by the Commission. If the company wish to hold these document in head office they must formally request permission of the Commission. During our site visit to Thames Clinic we spoke to staff and the manager to confirm good practice in the recruitment of staff and at this stage accept hat this is the case but it will need to be confirmed by examination of the documentation in due course. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 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): NMS 37, 39, 41 and 42: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that this is well managed service but the manager needs to be registered with the Commission. EVIDENCE: From our observation during the inspection it appeared that the manager has the required qualification and experience, is competent to run the home and meet its stated aims and objectives. The manager is able to describe a clear vision of the home based on the organisation’s values and priorities. Having spoken to a range of people including staff, residents and a visiting G.P. Doctor we conclude that the manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. Equality and diversity, human rights and person centred thinking are given Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 21 priority by the manager who is able to demonstrate a high level of understanding and demonstrate best practice in these areas. The new manager was able to demonstrate through formal qualification, robust operational systems and her professional experience that she is knowledgeable and competent in a range of areas, including service-specific good practice areas, that is the treatment and support of people addicted to alcohol and drugs. A quality assurance system is being developed but the home has in place a number of systems to support this including questionnaires and ‘end of stay’ check lists. It also keeps of record of outcomes for service users. In this way the service will be able to reflect upon its effectiveness in delivering what it offers, that is, clinically safe detoxification and preparation for next stage rehabilitation for those that choose it. The manager appears to provide an excellent role model for other employees. Other professionals, doctors, nurses, counsellors and support staff, see the manager as an imaginative and effective leader who consistently provides high quality services. They undertake regular training and understand and value opportunities for their continuing professional development. The manager ensures that staff follow the policies and procedures of the home. Staff have practice handbooks and easy access to training materials and documents. Practice and performance are discussed during supervision, staff training and team meetings. Spot checks and quality monitoring systems provide management evidence that practice reflects the home’s and organisation’s policies and procedures. We checked a range of records including visitors’ book, food, staff, residents files, complaints and so forth. We find record keeping to be competently and well managed including some computerised record keeping. There is strong evidence that the ethos of the home is open and transparent. The views of both residents and staff are listened to and valued and this is reflected in the feedback we received from the residents. The manager does however need to apply for registration, at which point she will be formally assessed as to her fitness and competence to manage this service and that assessment of her skills will take account of a wide range of issues including her health, police check, work history, her qualifications and experience. As a new service this home cannot be assessed as excellent without a track record of sustained very good outcomes for residents. A number of matters also need to be addressed as outlined in this report but this is a service that already appears to be providing very good outcomes and may achieve an excellent rating in the future. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 X 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X 3 3 2 Version 5.2 Page 23 Thames Clinic DS0000072398.V374966.R01.S.doc Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 13(6) Requirement Safeguarding: The home must obtain a copy of the local authority’s guidelines on the reporting of abuse. Safeguarding: The home must ensure that all staff have been trained in respect of the local authority’s guidelines on the reporting of abuse. Fire safety: The home must ensure that all fire doors can close fully to their stops. This is to protect residents from smoke entering their bedrooms. Fire safety: The home must ensure that all fire doors are kept closed unless held open with suitable devise that will ensure doors shut in the event of fire. This is to protect residents from fire or smoke. Manager: The home must ensure that a registered manager is in post by applying for registration without delay. This is so that residents will know that home is being managed by suitably competent person. Provider visits: The providers must arrange for a DS0000072398.V374966.R01.S.doc Timescale for action 30/07/09 2 YA23 13(6) 30/07/09 3 YA24 23(4) & (4A) 30/07/09 4 YA24 23(4) & (4A) 30/07/09 5 YA43 8 30/07/09 6 YA43 26 30/07/09 Thames Clinic Version 5.2 Page 24 representative to visit the service unannounced at monthly intervals and report their findings to the providers. Their monthly report must also be sent to the Commission. This is to ensure that the providers are aware of the day to day running of the home and are kept well informed about their accountability for the service. 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 YA20 Good Practice Recommendations Medicines: It is recommended that the home introduces a regular auditing system to monitor good practice in respect of the administration of medicines. This is to protect residents from possible errors in administration of medication. Thames Clinic DS0000072398.V374966.R01.S.doc Version 5.2 Page 25 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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. 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