Inspection on 11/09/07 for Thames Side

This inspection was carried out on 11th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Thames Side 16/10/08

Thames Side 13/02/08

Thames Side 16/03/07

Thames Side 25/05/06

Thames Side 07/11/05

Thames Side 17/05/05

Thames Side 01/02/05

Thames Side 01/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Thames Side Thames Side Beldham Gardens West Molesey Surrey KT8 1TF Lead Inspector Joseph Croft Unannounced Inspection 11th September 2007 10:00 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 Thames Side DS0000013813.V344461.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. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thames Side Address Thames Side Beldham Gardens West Molesey Surrey KT8 1TF 020 8939 3850 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) purchesed@anchor.org.uk www.anchor.org.uk Anchor Trust vacant post Care Home 60 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (8) Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the residents accommodated in the home up to 26 may fall within the category DE(E) and up to 8 may fall within the category PD(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 16th March 2007 Date of last inspection Brief Description of the Service: Thames Side is a purpose built residential care home to accommodate older people. It was opened January 2003 and the home is sited in its own grounds with good size, well-maintained gardens that are accessible to the residents. Car parking facilities are available at the front of the building. The home is well presented, providing accommodation for up to 60 service users over the age of 65 years. All bedrooms are for single occupancy and have en-suite facilities. The home has five separate units, each with its own sitting room, dining room and kitchen. Stairs or passenger lift accesses the upstairs accommodation. At the time of this site visit the fees for 2006/2007 were £741.00 per week. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 11th September 2007 using the ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the acting manager assisted him throughout. This site visit took place over a period of eight hours, commencing at 10:00 and concluding at 18:55. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The Inspector had discussions with members of staff on duty, and six residents. Discussions took place with one health care professional who was present during this site visit. Residents informed the Inspector that they were happy living at the home, and were complimentary about the care they receive from staff, stating that the staff look after them well. Residents informed the Inspector that the food was good, and they are offered a choice of foods. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the previous manager of the care home has been used as a source of evidence in this report. The current manager commenced her duties on the 1st July 2007. At the time of writing this report the Commission For Social Care Inspection had not received completed survey cards from residents, their relatives or other associated professionals. The inspector would like to thank the acting manager, members of staff and residents for their cooperation during this visit. Feedback was provided to the manager at the end of this site visit. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Pre-assessment details must be maintained in residents’ care files to ensure the assessed needs can be met by the home. All care plans and risk assessments must be reviewed to ensure that the health, personal and social care needs of residents are being met, and residents must be involved in the process. Records of medication must be accurately maintained and correspond to the stocks of medicines kept at the care home. Suitable arrangements must be in place to prevent infection, toxic conditions and the spread of infection in the care home. Staff recruitment files must include all information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001. A system for carrying out a quality assurance audit must be put into place, implemented and the outcomes made known to service users and their relatives. Fire doors must not be kept open through the use of wedges or other objects. Mandatory and specialist training must be provided to all members of staff working at the care home. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 7 The acting manager has been in post since the 1st July 2007 and had undertaken an audit against the National Minimum Standards for Older People, and therefore was aware of some shortfalls at the home before the site visit. 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. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 8 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 Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 9 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): Standards 3 and 6 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessments of the needs of prospective residents must be available in the care files. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) submitted to the Commission For Social Care Inspection indicates that the home completes preadmission assessments. The home has an admissions policy in place. Three care files were sampled as part of the case tracking process. There were no pre – admission assessments in these care files, therefore it was not possible to fully evidence this standard. These residents had been admitted to the home in 2004 and 2006. A requirement in regard to this has been made. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 10 The acting manager informed the Inspector that staff had not followed the organisation’s policy and procedure when they recently admitted a resident to the home. The organisation is currently dealing with this. The care file of the most recent admission to the home was viewed. This contained an appropriate assessment of needs, which was undertaken by the acting manager. Information in regard to religion and ethnicity were also included. The acting manager informed the Inspector that she would visit prospective residents at their current placement to undertake an assessment of needs. Prospective residents are invited to the home for a day when they can meet and have lunch with other residents, and view the bedroom they would occupy. The acting manager has produced an in-house procedure for admissions. During discussions, only one resident could recall visiting the home before they moved in. No resident could recall a visit from a member of staff to undertake an assessment. The acting manager stated the home does not provide intermediate care. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Individual plans of care and risk assessments must detail the care required to meet all aspects of health, personal and social care needs. The standard of medication administration must be improved to safeguard residents. EVIDENCE: Three care plans were sampled during the site visit. These care plans were incomplete and did not contain all the information as required. Information missing included medication, sight, communication, nutrition, religion, ethnicity and family involvement. Only one of the care plans sampled included information in regard to social activities. Care plans had not been reviewed between January and July 2007. Care plans had been signed by residents, however, during discussions, residents informed the Inspector that they were not aware of having a care plan. Shortfalls in regard to the care plans were identified during the Regulation 26 visit of June 2007 in regard to the lack of recording of information and failure Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 12 to review on a monthly basis. The acting manager informed the Inspector that she took up her post in July 2007, and undertook a full audit of the care plans. An action plan has been developed by the acting manager to ensure appropriate care planning is in place. The acting manager informed the Inspector that staff would commence using new Service User Plans after they have attended training that has been arranged for the 24th September 2007. Identified risks for residents were recorded and included risks in regard to mobility, but only one resident had a risk assessment in regard to falls. There was no nutritional risk assessments on residents’ files sampled. Risk assessments had not been reviewed on a regular basis. A requirement has been made that all care plans and risk assessments must be reviewed to ensure that the health, personal and social care needs of residents are being met, and residents must be involved in the process. Staff was knowledgeable about the care plans, but they informed the Inspector these are not always reviewed on a monthly basis. During discussions with staff and residents it was clear that health care professionals including a General Practitioner, District Nurse, Dentist and Chiropodist mainly support residents. Records of visits from health care professionals are maintained in the daily notes. During discussions, one visiting health care professional informed the Inspector that communication with the home is good, and staff carry out instructions that have been left. The health care professionals attend to any cases of pressure sores and testing blood sugar levels of diabetics, however, staff at the home have not received training in these areas. This is addressed under the Staffing section of this report. It was stated that the new manager has made improvements at the home, and health care professionals are called at the appropriate times. The home follows the organisations’ Policies and Procedures in regard to medication. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. The MAR sheets were viewed during this site visit. Evidence was viewed that medication is not being accurately recorded. One MAR sheet viewed did not correspond to the stocks of medicines kept at the care home, and the recording on another MAR sheet was not clear. The report for the Regulation 26 visit of August 2007 identified that signatures were missing on some of the MAR sheets, and there were no Team Leader daily medication audits of medication from the 28th July until the 14th August 2007. An immediate requirement has been made that the records of medication must be accurately Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 13 maintained and correspond to the stocks of medicines kept at the care home. The acting manager informed the Inspector that this would be addressed. Medication was appropriately stored in secure metal medicine cabinets in each of the five units. The home maintains a record of medication that has been returned to the Pharmacist, who since July 2007 has signed the returns documentation. The acting manager informed the Inspector that only staff who have received the appropriate training administer the medication. This was confirmed during discussions with staff, however, there was no evidence of this training in the training records sampled during the site visit. Training records viewed provided evidence that staff had attended training in regard to Rights and Responsibilities. Staff informed the Inspector that they treat residents with respect, they always knock on their bedroom doors and call them by their preferred names. This was confirmed during discussions with residents. Information provided in the AQAA informs that Equality and Diversity is met through recognising that each resident is an individual. Evidence found during the site visit did not fully support the information provided in the Annual Quality Assurance Assessment (AQAA) in regard to care plans. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service . People who use the service are provided with opportunities to improve their lifestyle, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a balanced diet. EVIDENCE: The home currently employs one activity co-ordinator who works thirty hours per week at the home. A weekly activity list is displayed on the notice boards in each of the five units. The acting manager stated that the home is currently advertising for a second activity co-ordinator who will work forty hours per week. This will enable activities to be offered throughout the whole day, as opposed to restricted times, and will include weekends. The home does not have its’ own transport, however, the acting manager informed the Inspector that links are being made with external organisations who provide transport services for older people. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 15 During discussions, residents informed the Inspector that activities are organised by the home, but they do not always wish to take part in them. Activities offered include flower arranging, quiz, darts, board games and art and craft. External entertainers visit the home, and children from local schools have entertained residents. Residents and staff informed the Inspector there are no restrictions on visitors the home. Visitors were present at the home during this site visit. Residents stated they make every day choices about their lives, they like their bedrooms and the staff. One resident informed the Inspector she calls her bedroom her flat, because it has an en-suite facility. It was noted that some residents have land line telephones in their bedrooms. The majority of residents living at the home are white British, and hold Christian beliefs. Staff and residents informed the Inspector that a local church leader attends the home on a monthly basis to provide a religious service. A representative from the Roman Catholic faith visits the home every Friday to administer Holy Communion. The home uses a four-week menu that is displayed on the notice boards in each of the units, however, on the day of the site visit these were displaying the wrong weeks menu. A good practice recommendation has been made that staff should ensure the correct menu is displayed in all the units. Menus offer a choice for every meal. The home has recently employed a chef. During discussions, the chef informed the Inspector that special diets are catered for. The chef has a record of all residents who require a special diet for health and religious reasons. The Inspector was informed that the menus are due to be reviewed as the winter months draw near. Menus were viewed, and they included meat, fish, pasta, fresh vegetables and fruit. Residents informed the Inspector that the food is good at the home, you always get a choice, and you can ask for something completely different from the menu. Residents stated that the chef contacts them throughout the week to ensure they are happy with the meals provided, and ask if they would like a different meal to the ones on offer that day. Each unit has its’ own dining room and a small kitchen. Tables were covered with tablecloths, and accommodate four residents on each table. Meals were not observed during this site visit. Residents were observed having drinks and snacks throughout the day, and drinks were available in the bedrooms visited during the site visit. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Residents are protected by staff having knowledge, training and an understanding of Safeguarding issues. EVIDENCE: The Commission For Social Care Inspection has not received any concerns, complaints or allegations in regard to the home. The home follows the organisation’s Complaints Policy and Procedure. This document includes the timescales for responding to complainants and the contact details for the Commission For Social Care Inspection. A large copy of the Complaints procedure was displayed in the entrance to the home. The home provides a Compliment, Concerns and Complaints leaflet to all residents, and are available in the home for visitors. The acting manager informed the Inspector that the organisation is currently dealing with a recent complaint. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 17 The acting manager has produced a new complaints folder that includes the date, nature of complaint, outcome and date the complainant was notified of the outcome. During discussions, residents stated they would talk to a member of staff if they needed to make a complaint. The home follows the organisation’s Policy and Procedure in regard to the Protection of Vulnerable Adults, and has a copy of the recent Surrey Multi – Agency Procedures that is available to staff. Evidence that staff had attended training in Safeguarding Adults was viewed in the six staff training files sampled during this site visit. The acting manager informed the Inspector that refresher training in Safeguarding Adults has been arranged for the 19th October 2007. The Inspector viewed evidence of this. During discussions staff informed the Inspector they would report all concerns to the manager, and would not hesitate to follow the organisation’s procedure in regard to Whistle Blowing. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 18 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): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are provided with clean and tidy communal and individual living space, however, identified areas require attention to ensure it continues to be a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. The home can accommodate 60 residents over the age of 65 years. All bedrooms are for single occupancy and have en-suite facilities. The home has five separate units, each with its own sitting room, dining room and kitchen. Stairs and/or a passenger lift access the upstairs accommodation. Residents’ bedrooms viewed were appropriately decorated containing their personal possessions and family photographs. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 19 The acting manager informed the Inspector that there are plans to use the ground floor of the care home as a designated Dementia unit. Residents stated they like their bedrooms and having their own belongings with them. Bedrooms viewed had call bells within easy reach of residents. At the time of the site visit the sound volume of alarm bells was found to be too low. This was attended to during the site visit. It was noted that the carpet in one bedroom had become stained. The acting manager informed the Inspector that this was due to be replaced. Bathrooms and toilets had paper towels and liquid soap. It was noted that the waste bins in the bathrooms/showers and toilets had no lids on, this was discussed with the acting manager, and arrangements were made for their replacement. Certain Substances Hazardous to Health (COSHH) were observed in some of the showers and bathrooms. The acting manager removed these. A requirement has been in regard to these, and that suitable arrangements must be in place to prevent infection, toxic conditions and the spread of infection in the care home. All communal areas are accessible to residents. On the day of this site visit the home was found to be clean, tidy and free from offensive odour. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory. The home has a recruitment policy and procedure in place; however, this has not always been followed when recruiting staff, therefore not fully protecting the residents. Attention is required in regard to training for staff. EVIDENCE: The acting manager informed the Inspector that there are two members of staff in each unit per shift. The duty rota was viewed, however, this showed shortfalls in the members of staff on duty in each unit. The acting manager explained that there are always eleven members of staff on duty each shift, which was confirmed on the duty rota, but staff are allocated to the units each day. There is always a floating member of staff on duty, and the acting manager is supernumerary to the rota. The acting manager informed the Inspector that the organisation is currently recruiting another five members of care staff. During the site visit staff were observed working in the units, and attending to the personal care needs of residents. Staff were addressing residents by their preferred names. Residents informed the Inspector that they like the staff and they are always available. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 21 On the day of the site visit the acting manager stated that 19 of the care staff working at the home hold the minimum of the NVQ level 2. A further five staff have registered to undertake this training, but evidence of this could not be produced. A good practice recommendation has been made that the acting manager should develop a plan of how the home can achieve 50 of staff holding the NVQ level 2 qualifications or above. The home follows the organisation’s Recruitment Policies and Procedures. Three staff files were sampled, including one member of staff who had recently commenced employment at the home. Each contained an application form, two references, Criminal Record Bureau and POVA first checks. However, two recruitment files did not record the reasons for gaps in employment. One application form was not clear as to who the last employer was, and therefore it was not possible to state that a reference had been obtained from this person’s last employment which involved working with vulnerable people. A requirement in regard to this has been made. During discussions, staff stated they had attended training in regard to Safeguarding Adults, Rights and Responsibilities and Dementia. This was evidenced in the six staff training files viewed by the Inspector during the site visit. The sampling of staff training files provided evidence of mandatory training that had been undertaken. However, it was noted that staff had not received training in regard to Food Handling and Hygiene, Infection Control and First Aid. Three staff had received training in regard to Health and Safety. Staff had received training in regard to Fire and Manual Handling. Staff had not received training in regard to tissue viability, diabetes or visual impairment. The acting manager informed the Inspector that the organisation has a training and development programme in place. A requirement has been made that mandatory and specialist training must be provided to all members of staff working at the care home. This will make sure people who use the service are supported by trained and competent members of staff. New staff undertake an induction-training programme that is in line with the Skills For Care common induction standards. Evidence found during the site visit did not fully support the information provided in the Annual Quality Assurance Assessment (AQAA). There were shortfalls in the recruitment and training files sampled. There was no information in regard to NVQ qualifications for staff. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 36 and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home recently had a change of manager. Issues in regard to care plans, risk assessments, health and safety, staff recruitment and training must be addressed to ensure the safety and welfare of the residents is maintained. EVIDENCE: The acting manager informed the Inspector that she commenced working in residential care in 1989, and has many years experience working at a senior level with older people. She commenced her position at home on the 1st July 2007, and stated that the application for registration as manager has been completed and will be submitted to the South East Regional Registration Team. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 23 Past training has included Dementia, medication, Rights and Responsibilities, disciplinary procedures, the A1 and A2 Assessors Award and the organisation’s home management training. The acting manager stated that she commenced the Registered Managers Award (RMA) in January 2007. The acting manager undertook a full audit of the home when she commenced her position in July 2007, and was honest throughout this site visit regarding the shortfalls that were identified. The Inspector was informed that all requirements made would be attended to. The home holds monthly meetings with residents, minutes of which were viewed during this site visit. The acting manager informed the Inspector that quality assurance surveys are undertaken on an annual basis. The home had completed surveys dated March 2007, however, a summary of the findings were not available at the home. The acting manager was not aware if a summary had been produced. A requirement in regard to this has been made. The acting manager stated that residents and their relatives are responsible for their finances. The home does hold small amounts of money for residents who request this. Senior staff and the area manager are responsible for the monitoring of monies held at the home. A requirement was made at the previous inspection that all staff receive formal supervision six times a year. The acting manager has commenced formal supervision, therefore this requirement will be assessed again at the next site visit. On the day of the site visit the fire alarm was activated. Doors in one unit closed automatically, however, two doors were kept open by the use of wedges. An immediate requirement has been made in regard to this. It was also noted that staff on the unit the Inspector was viewing did not follow the organisation’s Policies and Procedures in regard to instances of fire alarm activation. Residents were left on their own in this unit with the Inspector. This was discussed with the acting manager. The acting manager informed the Inspector by telephone that this had been addressed with the staff member concerned on the day after the site visit, and further training in this area has been arranged. Information provided in the AQAA informs that annual Health and Safety checks are undertaken. The home follows the organisation’s Health and Safety Policy and Procedure. During the site visit a sample of Health and Safety checks undertaken were viewed. These included the gas certificate, 12/07/07, fire detection and fighting equipment, 22/05/07, Portable Appliance Testing, 11/07/07, Legionella 23/02/06, fire risk assessments 27/07/06 and the Employers Liability Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 24 Insurance that expires on the 31/03/08. The fire extinguishers were last serviced on the 11/05/06, however, the acting manager has since informed the Inspector that these had been serviced on the 13/09/07. During discussions staff stated that the acting manager has only been at the home for two months, and did not feel they could make comments in regard to her management style as yet. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 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 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 (1) (b) Requirement Timescale for action 11/10/07 2. OP7 15 13 (4) Pre-admission assessment details must be maintained in residents’ care files to ensure the assessed needs can be met by the home. All care plans and risk 11/12/07 assessments must be reviewed to ensure that the health, personal and social care needs of residents are being met, and residents must be involved in the process. Records of medication must be accurately maintained and correspond to the stocks of medicines kept at the care home. This is to ensure that the health, safety and welfare of service users is maintained at all times. 11/09/07 3. OP9 13 (2) 4. OP26 13 (3) Substances Hazardous to Health (COSHH) must be appropriately stored at the home. Waste bins in all areas of the home must have a lid. 12/09/07 Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 27 5. OP29 19(1)(b) Schedule2 6. OP30 18(1)(a) (c)(i)(ii) Suitable arrangements must be in place to prevent infection, toxic conditions and the spread of infection in the care home. Staff recruitment files must include all information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001. Mandatory and specialist training must be provided to all members of staff working at the care home. This will make sure people who use the service are supported by trained and competent members of staff. 11/10/07 31/12/07 7. OP33 24 A system for carrying out a quality assurance audit must be put into place, implemented and the outcomes made known to service users and their relatives. 11/10/07 8. OP38 23 (4) (c) (i) This will ensure that the home is run in the best interests of the service users. Fire doors must not be kept open 11/09/07 through the use of wedges or other objects. This is to ensure that the health, safety and welfare of service users is maintained at all times. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 28 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. 2. Refer to Standard OP15 OP28 Good Practice Recommendations Staff should ensure the correct menu is displayed in all the units. The acting manager should develop a plan of how the home can achieve 50 of staff holding the NVQ level 2 qualifications or above. Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Thames Side DS0000013813.V344461.R01.S.doc Version 5.2 Page 30 - 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. 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