Please wait

Inspection on 29/04/09 for Thames Side

Also see our care home review for Thames Side for more information

This is the latest available inspection report for this service, carried out on 29th April 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home manager transfered to the home in February this year from another home within the same organisation and is preparing an application for registration. He has relevant experience and qualifications to manage the home and was registered prior to his transfer. The deputy manager is also relatively new to the home having also transfered from another home within the group. Discussions with both managers confirmed their awareness of both areas of service strengths and where improvements are necessary and are planned. The recently implemented weekly meetings for departmental managers within the home have been key to recent improvements, also internal quality assurance and auditing systems. We were informed by a team leader that recent reforms had raised standards and that team work and relationships between management and staff had improved. Both the team leader and staff consulted said they felt well supported and described an open management culture. A care assistant expressed the following opinion. " The last manager turned this home around and the new manager has built on her good work and is also very good. I can only speak for myself, but I find the home is a much nicer place to work than it was. If I am not happy about something I am quick to say and it is dealt with". Improvement in the home`s medication procedures and practice had mostly been sustained though a shortfall was identified during this inspection and drawn to the attention of management. Evidence was found of compliance with two requirements made at the time of an unannounced specialist pharmacist inspection we undertook in October 2008. The records sampled confirmed that allergies to medication are now recorded on both medication administration charts and care plans. There was evidence of people using services being administered medication at the dose and frequency prescribed by their general practitioner. The past high rate of staff turnover had subsided. Recent staff recruitment initiatives had been successful in filling most staff vacancies and building up numbers of care bank staff. Reliance on agency staff for maintaining staffing levels had reduced, improving continuity of care. The staff rotas sampled and feedback from people using services, visitors and staff indicated staffing levels were overall consistently maintained and appeared adequate.Other areas looked at included falls prevention risk assessments and management which includes issuing people at risk of falls with pendants to activate the call ball system for assistance. In the bedrooms sampled all but one of the beds were positioned so that people using services can access the call bell. The bedroom of the person who was the exception to this was being rearranged on the day of the visit at the same time as her own furniture was being brought in by her family. She had been reticent to have the room rearranged sooner preferring to wait until her furniture was delivered. She had been issued with a call bell pendant and had this with her in the lounge. Other areas assessed included arrangements for enabling people using services to access healthcare professionals. The home was understood to receive good support from both medical practices. We also examined procedures for enabling self-administration of medication after admission if people wish to retain this responsibility. Discussions with the deputy manager included assessment practice for a person in hospital ready for discharge back to the home. Also the management of a complaint investigation which had been temporarily suspended and was to be resumed. We examined how the home managed to balance the rights and risks of people using services in their access to the wider home environment. We were informed that mental capacity assessments were in the process of being undertaken, where necessary. The deputy manager was also currently reviewing personal evacuation plans for people using services. These detail dependency and mobility needs and contain instructions for their safe evacuation in the event of a fire. Discussions with some people using services individually and in groups identified a good level of satisfaction with the home`s services. Staff were observed to be kind and caring in their approach. Positive relationships evidently existed between individual staff and people using services. The home environment was comfortable, well-maintained, clean and hygienic and the atmosphere was warm and friendly. The expanded social activities programme is affording increased opportunities for social stimulation. We were told by a person using services, " I am well looked after and overall very happy living here. Staff are prompt in giving me the care and help I need. They are very good in the way they care for people with dementia though I feel they should select the activities they are involved in more carefully as they can`t always join in and don`t get the attention they need. I think some of the activities are excellent". The inspection found the home to have robust procedures for promoting nondiscriminatory practice, enabling people to maintain their rights and identities. Personal support practice is based on rights of dignity, equality, fairness, autonomy and respect.

What the care home could do better:

Improvement to the system for notifying us of things that have happened in the home had been sustained. Following a recent omission in a notification to care management the home has recognised the need to extend the scope of notifications to the regulator and care management. The home manager was referred to guidance on notifications under the Care Homes Regulations (amended). The need to ensure staff do not leave unattended medication trolleys with the door left open outside bedrooms whilst they are in the room administering medication was discussed. This practice was observed in one unit only and management confirmed the intention to take immediate remedial action. Onthis basis a requirement has not been made. The home`s management is aware of shortfalls in care records and has put in place a plan for improvement. Care records sampled were not all in sufficient detail to provide an audit trail of care and of significant events.

Random inspection report Care homes for older people Name: Address: Thames Side Beldham Gardens West Molesey Surrey KT8 1TF two star good service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Patricia Collins Date: 2 9 0 4 2 0 0 9 Information about the care home Name of care home: Address: Thames Side Beldham Gardens West Molesey Surrey KT8 1TF 02089393850 Telephone number: Fax number: Email address: Provider web address: tracey.kavanagh@anchor.org.uk www.anchor.org.uk Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Anchor Trust care home 61 Number of places (if applicable): Under 65 Over 65 0 61 dementia old age, not falling within any other category Conditions of registration: 61 0 The maximum number of service users to be accommodated is 61. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia (DE). Date of last inspection Brief description of the care home Thames Side is a purpose built care home operated by Anchor Trust Ltd, a national care services provider. The home provides personal care and accommodation for up to 61 older people. It opened in January 2003 and is set in its own grounds with wellmaintained gardens accessible to people using its services. Car parking facilities are at the front of the building. The home is on a main road within walking distance of shops Care Homes for Older People Page 2 of 9 Brief description of the care home and the River Thames and convenient for all community amenities. Accommodation is arranged in five living units over three floors, accessible by a passenger lift. All bedrooms are for single occupancy and have en-suite facilities. Each unit has its own sitting room, dining room and kitchen. Care Homes for Older People Page 3 of 9 What we found: This unannounced inspection was undertaken by one inspector over four hours to assess how well the home is achieving positive outcomes for the people using its services. The report will say what we found as it is written on behalf of the Care Quality Commission. The range of accumulated evidence used to inform judgements about the home include direct observations during a tour of four of the residential living units. We viewed most communal areas in these units and sampled bedrooms. We spoke with fifteen people using the homes services and three relatives during the visit. We also sampled some records, observed care and medication practice and had discussions with the home manager, deputy manager, a team leader, six care staff, the house keeper and an activities coordinator. What the care home does well: The home manager transfered to the home in February this year from another home within the same organisation and is preparing an application for registration. He has relevant experience and qualifications to manage the home and was registered prior to his transfer. The deputy manager is also relatively new to the home having also transfered from another home within the group. Discussions with both managers confirmed their awareness of both areas of service strengths and where improvements are necessary and are planned. The recently implemented weekly meetings for departmental managers within the home have been key to recent improvements, also internal quality assurance and auditing systems. We were informed by a team leader that recent reforms had raised standards and that team work and relationships between management and staff had improved. Both the team leader and staff consulted said they felt well supported and described an open management culture. A care assistant expressed the following opinion. The last manager turned this home around and the new manager has built on her good work and is also very good. I can only speak for myself, but I find the home is a much nicer place to work than it was. If I am not happy about something I am quick to say and it is dealt with. Improvement in the homes medication procedures and practice had mostly been sustained though a shortfall was identified during this inspection and drawn to the attention of management. Evidence was found of compliance with two requirements made at the time of an unannounced specialist pharmacist inspection we undertook in October 2008. The records sampled confirmed that allergies to medication are now recorded on both medication administration charts and care plans. There was evidence of people using services being administered medication at the dose and frequency prescribed by their general practitioner. The past high rate of staff turnover had subsided. Recent staff recruitment initiatives had been successful in filling most staff vacancies and building up numbers of care bank staff. Reliance on agency staff for maintaining staffing levels had reduced, improving continuity of care. The staff rotas sampled and feedback from people using services, visitors and staff indicated staffing levels were overall consistently maintained and appeared adequate. Care Homes for Older People Page 4 of 9 Other areas looked at included falls prevention risk assessments and management which includes issuing people at risk of falls with pendants to activate the call ball system for assistance. In the bedrooms sampled all but one of the beds were positioned so that people using services can access the call bell. The bedroom of the person who was the exception to this was being rearranged on the day of the visit at the same time as her own furniture was being brought in by her family. She had been reticent to have the room rearranged sooner preferring to wait until her furniture was delivered. She had been issued with a call bell pendant and had this with her in the lounge. Other areas assessed included arrangements for enabling people using services to access healthcare professionals. The home was understood to receive good support from both medical practices. We also examined procedures for enabling self-administration of medication after admission if people wish to retain this responsibility. Discussions with the deputy manager included assessment practice for a person in hospital ready for discharge back to the home. Also the management of a complaint investigation which had been temporarily suspended and was to be resumed. We examined how the home managed to balance the rights and risks of people using services in their access to the wider home environment. We were informed that mental capacity assessments were in the process of being undertaken, where necessary. The deputy manager was also currently reviewing personal evacuation plans for people using services. These detail dependency and mobility needs and contain instructions for their safe evacuation in the event of a fire. Discussions with some people using services individually and in groups identified a good level of satisfaction with the homes services. Staff were observed to be kind and caring in their approach. Positive relationships evidently existed between individual staff and people using services. The home environment was comfortable, well-maintained, clean and hygienic and the atmosphere was warm and friendly. The expanded social activities programme is affording increased opportunities for social stimulation. We were told by a person using services, I am well looked after and overall very happy living here. Staff are prompt in giving me the care and help I need. They are very good in the way they care for people with dementia though I feel they should select the activities they are involved in more carefully as they cant always join in and dont get the attention they need. I think some of the activities are excellent. The inspection found the home to have robust procedures for promoting nondiscriminatory practice, enabling people to maintain their rights and identities. Personal support practice is based on rights of dignity, equality, fairness, autonomy and respect. What they could do better: Improvement to the system for notifying us of things that have happened in the home had been sustained. Following a recent omission in a notification to care management the home has recognised the need to extend the scope of notifications to the regulator and care management. The home manager was referred to guidance on notifications under the Care Homes Regulations (amended). The need to ensure staff do not leave unattended medication trolleys with the door left open outside bedrooms whilst they are in the room administering medication was discussed. This practice was observed in one unit only and management confirmed the intention to take immediate remedial action. On Care Homes for Older People Page 5 of 9 this basis a requirement has not been made. The homes management is aware of shortfalls in care records and has put in place a plan for improvement. Care records sampled were not all in sufficient detail to provide an audit trail of care and of significant events. 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 set out on page 2. Care Homes for Older People Page 6 of 9 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 7 of 9 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 8 of 9 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 Helpline: 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. 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. Care Homes for Older People Page 9 of 9 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!