Inspection on 02/06/09 for Thackeray House

This inspection was carried out on 2nd June 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thackeray House 12/11/09

Thackeray House 12/06/07

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 07/08/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Thackeray House Thackeray House 58 Addiscombe Road Croydon Surrey CR0 5PH     The quality rating for this care home is:   one star adequate service 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 assessment of the service. We call this a ‘key’ inspection. Lead inspector: Mohammad Peerbux     Date: 0 3 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Thackeray House 58 Addiscombe Road Thackeray House Croydon Surrey CR0 5PH 02086498800 02086881393 thackeray@barchester.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Barchester Healthcare Homes Ltd care home 39 Number of places (if applicable): Under 65 Over 65 39 old age, not falling within any other category Additional conditions: 0 The maximum number of service users who can be accommodated is: 39 The registered person may provide the following category of service only: Care home with nursing (CRH - N) 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 - Code OP Date of last inspection Brief description of the care home Thackeray House is a purpose-built nursing home providing care to a maximum of thirty-nine residents. 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 wellmaintained 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. Care Homes for Older People Page 4 of 28 Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced visit to the home was undertaken as a part of the inspection process for the year 2009/2010. 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. The registered manager facilitated this inspection. Some of the residents were spoken to and they commented positively on the care they are receiving. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. All registered adult services are now required to fill in an annual quality assurance assessment (AQAA).It is a self-assessment that the provider (owner) must complete Care Homes for Older People Page 6 of 28 every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some information from this AQAA is included in the report. What the care home does well: What has improved since the last inspection? What they could do better: 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 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. Care Homes for Older People Page 8 of 28 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. No one is admitted into the home now without a comprehensive assessment being undertaken, this ensures that the home is aware of how they will need to be supported and be confident that their healthcare needs can be met. Evidence: Before agreeing admission the service carefully considers the needs assessment for the individual and the capacity of the home to meet their needs. Prospective residents are given the opportunity to spend time in the home. They are visited by an experienced member of the team to determine their care needs. As part of the preadmission process the home consults with the relatives and the multidisciplinary team who have been involved in the prospective residents care where appropriate. Four residents files were sampled at random and they all had a pre-admission assessment carried out. Care Homes for Older People Page 10 of 28 Evidence: This home does not offer intermediate care. Care Homes for Older People Page 11 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health, personal and social care needs are not being appropriately met as their care plans do not always identify all their needs.The practices for administration of medications are inadequate and potentially places residents at risk. Evidence: Four residents care plans were sampled at random and it was noted they did not always include all information necessary to deliver the residents care needs. For example one resident suffers from high blood pressure and arthritis, these were not covered in their care plan. Another resident suffers from asthma and epilepsy and again these were not covered in their plan of care. It was also noted that all four care plans which were sampled did not cover all the residents needs as identified on their pre-admission assessment. This was discussed with the manager who gave assurance that all the care plans would be checked to ensure that all residents needs are identified. Residents care plans must include all aspects of their health, personal and social care Care Homes for Older People Page 12 of 28 Evidence: needs to ensure that all their needs are met. The residents plan must meet relevant clinical guidelines produced by the relevant professional bodies concerned with the care of older people, and include a risk assessment, with particular attention to prevention of falls. The daily records were sampled and it was noted that they did not always contain all the care that had been provided to the residents as detailed in the care plan. Detailed daily records will help the manager to audit the care being provided to the residents, and ensure that staff are following the guidelines in the care plans. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base the monthly review and to record that they are following the assessment of needs. With regards to the monthly care plan reviews it was noted that staff were dating and signing on the care plans as the review process. No further information was being recorded on the Progress and Evaluation Record. Residents care plans must be used as a working document and must be reviewed regularly involving the person and their representatives, as appropriate. Reviews must focus on asking what has worked for the individual, where there is progress, achievements, concerns and identifies action points. This will ensure that residents needs are being fully met. Residents have access to healthcare and remedial services. Staff make sure that those who are fit and well enough are encouraged to be independent, have regular appointments and visit local health care services. The health care needs of residents unable to leave the home are managed by visits from local health care services. However as mentioned above not all care needs are being identified and residents care plans are not always being reviewed and/or updated so it would difficult for staff to meet residents needs fully. There was evidence in the care plans of health care treatment and intervention, and a record of visiting professionals. The medication administration records were audited and it was noted that there were several instances they were not accurate. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. One example is 14 tablets of Trimethoprim 200mg was prescribed for one resident however there were 15 signatures on the medication administration record. The manager was not able to comment on why there were fifteen signatures. The registered person must ensure that the administration/non-administration of all medication is recorded accurately at all times. It was also noted that one staff had clearly signed for an item of medication that had not been taken by the resident as the tablet was still on their table. The Nursing and Care Homes for Older People Page 13 of 28 Evidence: Midwifery Council (NMC) Code of Professional Conduct requires each nurse to be individually accountable for making sure that all medicines are administered correctly. All staff must make an accurate record, immediately after observing a resident taking or refusing their medicines. During our visit on both days we noted that items of medication were being kept above the recommended level of 25 degrees Celsius. The room temperature where items of medication were kept was 26 degrees Celsius . All items of medication must be kept at the recommended temperature level for the safety of residents. The home is reminded that medicines in the custody of the home must be handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971 and Nursing staff abide by the NMC Standards for the administration of medicines. All of the residents appeared clean, well dressed and cared for. Any personal care is given in their rooms and they told us staff are good to me and I am happy here and the staff look after me well. The staff that we met during the inspection were very pleasant and seemed to have good relationships with the people that they were caring for. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed residents, and they were seen to be polite and friendly. Care Homes for Older People Page 14 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in this home consider that they have a lifestyle, which suits them. They are encouraged to make choices in order to maximise their independence wherever possible and they enjoy the meals that are served in the home. Evidence: The service has a strong commitment to enabling residents to develop or maintain their skills, including social, emotional, communication, and independent living skills. During the pre-admission assessment and on admission the home continues to collect information on what activities the individual was engaged in and they are assisted to continue with the same activity as long as they can. An activity organiser has been recruited and the home has purchased a minibus for outside activities. Further training has been arranged for the activity organiser to improve activities for the people using the service.Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. People who use the service have the opportunity to develop and maintain important personal and family relationships.The staff practices promote individual rights and choice, but also consider the protection of individuals in supporting them to make Care Homes for Older People Page 15 of 28 Evidence: informed choices. The home tries to be flexible and attempts to provide a service that is as individual as possible, using its staff and resources effectively. Residents can access and enjoy the opportunities available in their local community.The home has sought the views of the residents and considered their varied interests when planning the routines of daily living and arranging activities both in the home and the community. Relatives are encouraged to take residents out with them when they are attending church whenever possible. The menu is varied with a number of choices including a healthy option. On admission the chef normally meets with the resident to discuss their dietary preferences including their beliefs and religious restrictions. The menu includes a variety of dishes and individuals are encouraged to try new and sometimes unfamiliar food. Care Homes for Older People Page 16 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns, and are protected from abuse, and have their rights protected. Evidence: The ethos of the home is that it welcomes complaints and suggestions. All complaints made and the actions taken in response to them are fully recorded. A review of the number and nature of complaints made is used as part of the quality assurance procedures in use at the service. The home learns from complaints in order to improve its service. Advocacy service information is available to the residents, this offers guidance on how people can access an independent advocate. Where people who use the service lack capacity the manager facilitates access to available advocacy services. A comments box is available at the reception should anyone wish to put their comments, concerns or complaints in writing. There is a clear system for staff to report concerns about colleagues and managers which ensures that concerns are investigated in line with local policies and procedures. The home is clear when an incident needs to be referred to the Local Authority as part of the local safeguarding procedures. Most of the staff working within the home are fully trained in safeguarding adults and know how to respond in the event of an Care Homes for Older People Page 17 of 28 Evidence: alert.Two staff members have attended Safeguarding Adult training with the local social services team and they now train the staff in the home on the subject. Care Homes for Older People Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables residents to live in a wellmaintained and comfortable environment, which encourages independence. Evidence: The home provides a physical environment that is appropriate to the specific needs of the people who live there. Residents bedrooms are personalised to reflect their individual needs, and personalities. The home is comfortable, and has a programme to improve the decoration, fixtures and fittings.Decoration of all commons areas of the care home is reviewed regularly and updated. Closed-circuit television (CCTV) cameras are restricted to the main entrance areas for security purposes only and does not intrude on the daily life of people who use the service. The home has installed air conditioning in the conservatory to ensure that it is not too hot for the residents for the summer months.They have also employed a gardener to keep the garden looking tidy with more seasonal flowers. The home is kept clean and hygienic and free from offensive odours throughout. The home has a very dedicated housekeeping team led by a housekeeper with 10 years of experience. Systems are in place to control infection in accordance with relevant legislation and published professional guidance.However it was noted that there was a Care Homes for Older People Page 19 of 28 Evidence: risk of the contamination of water supply through backflow as the shower hoses were too long. A requirement has been issued under the health and safety standard.The home has a hygiene and infection control coordinator/link nurse responsible for monitoring that all the staff practices are within infection control policies and guidelines. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. Evidence: People have confidence in the staff who 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 people who use the service. The home has 5 housekeeping staff and 5 catering staff including two chefs. This ensures that standards relating to food, meals and nutrition are fully met and that the home is maintained in a clean and hygienic state and free from unpleasant odours.The home has recently employs a maintenance person and an activity organiser. The manager informed us that more than 80 of staff have an NVQ qualification at level 2 in care. The service has a recruitment procedure that meets statutory requirements and the National Minimum Standard. Three staff files were examined at random and found to contain information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB Care Homes for Older People Page 21 of 28 Evidence: check and proof of their identity. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the NMS. The manager is aware that there are some gaps in the training programme and has plans to deal with this. The manager is also able to recognise when additional training is needed. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect and has effective quality assurance systems developed by a qualified, competent manager. Evidence: The registered manager has the required qualifications and experience, and is competent to run the home. There was strong evidence that the ethos of the home is open and transparent. The views of both people who use the service and staff are listened to, and valued.The manager has a clear understanding of the key principles and focus of the service based on organisational values and priorities. They work to continuously improve the service. Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are in place to measure success in meeting the aims, objectives and statement of purpose . The results of resident surveys are published and made Care Homes for Older People Page 23 of 28 Evidence: available to current and prospective people, their representatives and other interested parties, including the Commission. The annual quality assurance assessment (AQAA) was received on time and contained clear, relevant information that was supported by a wide range of evidence. The AQAA lets us know about changes the home has made and where they still need to make improvements. It shows clearly how they are going to do this. The manager informed us that the home does not look after any residents money. Records with regards to health and safety are generally of a good standard however action must be taken to prevent the contamination of the water supply. A Health and Safety audit is completed by the home periodically and an action plan is drawn up to address identified issues. The organisation also employs an independent health and safety body which completes an audit yearly and give advice on issues identified. Care Homes for Older People Page 24 of 28 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, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 28 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, Care Homes 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 1 7 15 Residents care plans must also be reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. To ensure that all their needs are met. 31/08/2009 2 7 15 Residents care plans must include all aspects of their health, personal and social care needs. To ensure that all their needs are met. 31/08/2009 3 9 13 The administration/nonadministration of all medication must be recorded accurately at all times. For the health and safety of residents. 15/06/2009 Care Homes for Older People Page 26 of 28 4 9 13 All items of medication must 15/06/2009 be kept at the recommended temperature level. For the safety of residents. 5 38 13 Action must be taken to 15/06/2009 prevent the contamination of the water supply. For the safety of residents and staff. 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 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 28 of 28 - 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!