Inspection on 09/02/06 for Sir Jules Thorn Court and Mary Court

This inspection was carried out on 9th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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.

Other inspections for this house

Sir Jules Thorn Court and Mary... 14/01/09

Sir Jules Thorn Court and Mary... 10/01/08

Sir Jules Thorn Court and Mary... 21/11/06

Sir Jules Thorn Court and Mary... 15/08/05

Sir Jules Thorn Court and Mary... 20/12/04

Sir Jules Thorn Court and Mary... 10/06/04

Sir Jules Thorn Court and Mary... 15/01/04

Sir Jules Thorn Court and Mary... 21/10/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sir Jules Thorne Court 29-35 Prince Of Wales Drive Battersea London SW11 4SL Lead Inspector Janet Pitt Unannounced Inspection 9th February 2006 10:15 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 Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 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. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sir Jules Thorne Court Address 29-35 Prince Of Wales Drive Battersea London SW11 4SL 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) 020 7738 0280 azadh@serviceshouses.org.uk Servite Houses Mr K A Mooniaruck Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (30) Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Those being in the category of Elderly Mentally Frail Those being in the category of Mental Health cannot be liable to be detained under the Mental Health Act 1983. 15th August 2005 Date of last inspection Brief Description of the Service: Sir Jules Thorn and Mary Court provides nursing care for up to thirty people and personal care for one person. The thirty residents who require nursing care live in accommodation arranged over two floors which has four units, known as ‘clusters’. Each cluster has its own lounge and kitchenette. There is a communal dining room. Residents are able to access a small garden with seating areas. The one resident who requires personal care lives in Mary Court, which is part of the same complex as Sir Jules Thorn; there is an interlinking door between the two units. The resident in Mary Court has their own flat, comprising of a bedroom, lounge, bathroom and kitchenette, with access to bathing facilities with equipment. The home is situated in Battersea, close to Battersea Park. There are accessible road and bus links to north and south London. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken unannounced by one inspector and lasted a total of five and a quarter hours. Care documentation and records relating to staff recruitment and training were examined. A tour of the premises was undertaken. The inspector spoke with four members of staff and two visitors. The inspection focused on Standards not assessed at the previous inspection and requirements made. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 6 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 Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these Standards were assessed at this inspection. Core Standard 3 was met at the previous inspection. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, and 10. Residents are treated with respect and their dignity maintained. Recording of care given indicates what has occurred, but requires further improvement to reflect night-time care. Residents are protected from harm by clear and safe medication procedures. EVIDENCE: Residents are protected from harm by a clear audit trail of medicines within the home. There are suitable policies in place detailing handling of medicines. Examination of the medicine records showed that allergies were recorded and there were no gaps in recording of administration. Medicines are signed for when received and boxes are dated when commenced. There has been significant improvement in the daily records of care given, which gives a clear picture of what has occurred, this evidences that residents’ needs are met. There was evidence in the care plans of residents’ preferred daily routine, which was reflected, in the daily records. Recording of care was noted to be good by the day staff with entries containing full information on activities throughout the day and food eaten, however there is still some weakness with the recording by evening and night staff, examples Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 9 being ‘had a good evening’ and ‘seemed comfortable’. This does not comply with the Nursing and Midwifery Council’s guidance on record keeping. Residents are treated with respect and their dignity maintained. Staff were noted to inform residents what actions they were about to take and wait until the resident was able to proceed. Two student on placement at the home said that ‘staff treated residents with respect’. Appropriate use of other professional involvement such as psychologists was noted; this makes sure that all aspects of need are met. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 15 Residents are able to choose where to eat and have a choice of menu at each meal. Visitors are made welcome in the home and staff make sure that residents have choice and control over their lives. EVIDENCE: Residents are able to receive visitors in private. Visitors spoken with during the inspection indicated that they are made to feel welcome when they visit and are kept informed of their relative’s condition. There was evidence within the care documentation of resident’s representatives being involved in the care planning process. One visitor said that when they were choosing a care home they visited Sir Jules Thorn unannounced and was pleased with the response of the staff and the opportunity to view the home. A member of staff said that residents are able to choose how they spend their day and are able to eat with other residents, in the clusters or in their rooms. Residents are able to have their meals in a sociable setting. Residents have a choice of meals and the dining area is able to seat all residents. Staff were observed to be seated when assisting residents with lunch. Portion size was adequate and condiments were available at each table for resident use. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents are protected from harm by the policies and procedures in place for Adult Protection; staff are routinely informed of what should occur if there is suspected abuse. EVIDENCE: There have been no Protection of Adults investigations in the home since the previous inspection. The manager confirmed that awareness of potential abuse is highlighted at monthly staff meetings and training is provided. The home has a local adult protection policy in place, which is satisfactory, and a copy of the boroughs guidance. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Residents live in a clean and tidy environment. They are able to personalise their rooms and there is adequate equipment in place to meet care needs. Areas requiring redecoration have been identified and plans are in place to undertake this work. EVIDENCE: Residents live in an environment, which is adequately maintained and suitable for their needs. The monthly visit reports from the provider indicated that urgent redecoration work was to be carried out on the corridors and doorways of the home, where damage has occurred. The manager, who also stated that there was an ongoing redecoration programme in place, confirmed this. The students spoken with said they had found the home to be clean and tidy and free from odour. Dust was noted on the ledges above the doors and this was dealt with immediately, to minimise cross infection risks to residents. Residents’ rooms were noted to be personalised with suitable furniture and furnishings. There was appropriate hoists and handling equipment available to enable staff to care for residents. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 13 Air conditioning unit have been installed in the lounges of the clusters to make sure that residents are comfortable and the manager indicated that lighting is to be improved in the dining room. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 Residents’ are cared for by staff that are appropriately selected and trained. EVIDENCE: Residents are protected from potential harm by the recruitment process within the home. Staff files contained details of relevant checks on potential workers. Contracts of employment, job descriptions and a recent photograph of the worker were in each file examined. The manager is in the process of transferring training that staff have undertaken into a training portfolio, which complies with training standards and enables clear tracking of training undertaken or required by staff. The in-house training programme provides training in areas such as infection control, care planning, wound management and communication. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 and 35 Residents live in a home where there is a stable staff group and an approachable management team. The home has carried out a customer satisfaction survey, which produced positive results. EVIDENCE: Residents live in a home, which benefits from stable management. The manager has many years experience in running the home and is available to staff, residents and visitors. Residents’ choices are met when possible and residents are able to discuss any issues they may have with the manager or staff members. Residents’ financial interests are protected by policies and practices at the home. A customer satisfaction survey was undertaken in February 2005, by an independent consultant, it is recommended that this is repeated. The survey indicated a high level of satisfaction with care provided, communication, food, activities, cleanliness and presentation of residents. Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X X Sir Jules Thorne Court DS0000019122.V283805.R01.S.doc Version 5.1 Page 17 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 Regulation 15 Requirement The registered person must ensure that daily records of care reflect actual care given, with particular reference to night time care. Timescale for action 30/05/06 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 OP33 Good Practice Recommendations It is recommended that an external consultant undertake a customer satisfaction survey annually. 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