Inspection on 12/06/07 for Thackeray House

This inspection was carried out on 12th June 2007.

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

Thackeray House 12/11/09

Thackeray House 02/06/09

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Thackeray House Thackeray House 58 Addiscombe Road Croydon Surrey CR0 5PH Lead Inspector Mohammad Peerbux Key Unannounced Inspection 12th June 2007 9:00am 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 Thackeray House DS0000069369.V340342.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. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thackeray House Address Thackeray House 58 Addiscombe Road Croydon Surrey CR0 5PH 020 8649 8800 020 8688 1393 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) Barchester Healthcare Homes Ltd Post Vacant Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Terminally ill (10) of places Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2006 Brief Description of the Service: Thackeray House is a purpose-built nursing home providing care to a maximum of thirty-nine service users. The home provides care for elderly frail residents and also offers a specific palliative care service. Communal space includes a large dining area, a pleasant conservatory and a quiet lounge. The latter two areas overlook a well-maintained rear garden. The home is ideally situated as it is close to public transport - the tram passes the front door - and it is a short walk from East Croydon railway station and the excellent transport links this affords. The centre of Croydon, with vast shopping and cultural opportunities is only a short distance away. Parking is available directly outside the house. The range of weekly fees is between £528 and £915. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. In writing the report consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. This was the home’s first inspection for the year 2007/08. It took place over five hours. Some times were spent looking at the policies and procedures, records, talking to some residents, staff and the acting manager. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. What the service does well: Comprehensive information about the home and the services offered (included in the Statement of Purpose and Service User Guide) is available, and potential residents and their relatives are encouraged to visit the home, enabling an informed choice regarding the suitability of the home. Comments from residents were generally positive, with indication that staff are kind and helpful in meeting their care needs. They were observed to be treated with respect by staff and to have their privacy and dignity respected. The home has a settled staff group and has the numbers and skill mix of staff sufficient to meet service users’ needs. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them. The home has a training plan and intends to train its staff in health care to achieve accreditation. The home’s recruitment procedures protect the service users through vigorous staff vetting. The home is pleasantly designed and furnished, providing communal living, recreational and dining space that meets individual and collective needs. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides all of the information needed for potential residents and their relatives to make an informed decision about moving in to the home. EVIDENCE: Prospective residents have the information they need to make an informed choice about where to live. The home has developed a statement of purpose, which sets out the aims and objectives of the home, and includes a resident guide, which provides basic information about the service. The guide is made available to residents in a standard format. Both documents are in the process of being reviewed by the management of the home. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 9 Admissions are not made to the home until a full needs assessment has been undertaken. The home are then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. For people whom are self funding and without a care management assessment, then the assessment is always undertaken by a skilled and experienced member of staff. Evidence confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident. Intermediate care for rehabilitation and return to the community is not provided by this home. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally residents’ personal, physical and emotional health needs are being met and reviewed. EVIDENCE: The home has a strong belief that it is essential to involve residents as far as possible in the planning of care that affects their lifestyle and quality of life. Residents have a plan that has been agreed with them where they are able to do so. This is written in plain language, is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. The plan also includes a risk assessment. Areas have been identified where staff are willing to support residents to take some risks, which may have an impact on their rights. Evidence of updating information and changing actions appears in the care plans in line with a requirement made at the last Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 11 inspection. Further training has also been arranged for staff with regards to writing care plans comprehensively. The home actively promotes the residents’ right of access to the health and remedial services that they need, both within the home and in the community. Records show that the home arranges for health professionals to visit frail residents in the home and provides facilities to carry out treatment. The incidence of pressure sores, their treatment and outcome, are recorded in the resident ’s individual plan of care and reviewed on a continuing basis. The tissue viability nurse is in regular contact with the home to advise them accordingly. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. The home has worked towards improving the medication systems, as there were concerns raised before with regards to the administration and storage of medication. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms. Residents who were spoken to stated that they are happy with the way that the staff deliver their care and respect their dignity. One resident stated, “I am happy here and the staff are kind to me”. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. During a recent relatives’ meeting, which was also attended by the Commission, a number of positive comments were made as far as the care in the home is concerned. There were some concerns raised with regards to activities during the weekend, fees being paid, staffing level in the home and the food being cold at times. The acting manager had agreed to look into all the concerns raised. Most of the concerns have already been addressed at the times of this inspection. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Staff are aware of the need to plan the routines and activities of the home in a way, which meets the choice, and wishes of residents. The home tries to be flexible and attempts to provide a service, which is as individual as possible by using its staff and resources effectively. As far as possible the residents are consulted on how the home can work to provide them with a flexible lifestyle, and to achieve their wishes. The home has developed a system for displaying information and bringing attention to community events and activities. When residents have particular interests every effort is made by staff to help the Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 13 resident maintain their interest and keep up any community involvement. A number of relatives and residents commented positively on the activities being provided in the home during a recent relatives’ meeting. The priest visits the home every month to give Holy Communion. Family and friends feel welcome and know they can visit the home at any time. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. It is clear that the home encourages individuals and groups from the community to visit the home. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. Residents have the choice to bring personal possessions with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. The food in the home is of good quality, well presented and meets the dietary needs of residents. The cook is experienced, consults with residents and tries to meet the preferences and suggested dishes when preparing the menu. Staff are trained to help those residents who need help when eating and are sensitive in their approach. Residents are able to choose to eat in their own room if they wish. Regular drinks and snacks are available. Again there were positive feedback from relatives and residents about the quality of food being provided. One resident stated, “the food is very good”. There has been concern with food being cold when being served to residents; the acting manager has addressed this concern by buying two new trolleys to keep the food warm. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 14 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. EVIDENCE: The home has a complaints procedure that is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint. In general, individuals and others associated with the home say that they are satisfied with the service, feel safe and well supported. All staff working at the home know the importance of taking the views of residents seriously, and of listening to and responding to raised issues. The home is clear when an incident needs to be referred to the Local Authority as part of the local Safeguarding procedures in place. Most of the staff working within the home are fully trained in Safeguarding Adults and know how to respond in the event of an alert. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 15 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. EVIDENCE: The management and staff encourage residents to see the home as their own home. It provides a very well maintained, safe, comfortable, attractive home, which has all the specialist equipment and adaptations needed to meet individual resident’s needs. As well as a good selection of general aids such as hoists. The home also ensures that equipment is individualised for each resident for example pressure relief mattress. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 16 The home is always very well lit, clean and tidy and smells fresh. The management has a proactive infection control policy and they work closely with external specialists, e.g. infection control, and their own staff to ensure that infections are minimised. Clinical waste is properly managed and stored. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 17 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): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the service users’ needs and provide consistency and to ensure their safety. The home’s recruitment procedures protect the service users through vigorous staff vetting. EVIDENCE: Residents and or their relatives spoken to during the visit all said they were happy with the care provided, they found the staff friendly and helpful. Generally residents have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. The home has recently employed a senior nurse and is just waiting for the approval of her work permit. Another senior nurse is also in the process of being recruited. The acting manager informed that more than 75 of staff have an NVQ level qualification at level 2. The home has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 18 the importance of effective recruitment procedures in the delivery of good quality services and for the protection of residents. Three staff files were examined at random and found to contain the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The home is also able to recognise when additional training is needed, and attempts to plan over time to provide this training. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home management generally provides guidance and direction to staff to ensure service users receive consistent quality care. There is a good equality monitoring system and this ensures the home is run in a way that is in the best interests of the service users. EVIDENCE: The acting manager has the required experience and is competent to run the home. He works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running of the home. The acting manager is resident Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 20 focused and leads and supports a strong staff team. He is also aware of current developments both nationally and by CSCI and plans the service accordingly. He has applied through the Commission to be the registered manager for the home. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The results of service user surveys are published and made available to current and prospective users, their representatives and other interested parties, including the Commission. Residents have the opportunity to manage their own money if they wish, and some facilities are provided to help keep it safe. From staff files sampled at random there were evidence that care workers are being supervised on a regular basis. However the supervision of qualified staff would be more regular when the new senior nurses start employment, as the supervision would then be shared between the acting manager and the senior nurses. The home has a health and safety policy that generally meets health and safety requirements and legislation. It is aware of the areas where they need to make improvements and has an action plan for undertaking the work. Certificates relating to health and safety were up to date servicing certificates. Records are of a good standard and are routinely completed. Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Thackeray House DS0000069369.V340342.R01.S.doc Version 5.2 Page 24 - 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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