Inspection on 16/03/07 for Thames Side

This inspection was carried out on 16th March 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

Thames Side 16/10/08

Thames Side 13/02/08

Thames Side 11/09/07

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 Kenneth Dunn Unannounced Inspection 16th March 2007 09:30 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.V330002.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.V330002.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) sharon.blackwell@anchor.org Anchor Trust Mr Derek Purchese 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.V330002.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 25th May 2006 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 a good standard of 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 six 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.V330002.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of a key inspection and took place over five hours commencing at 09:30 and finishing at 13:30. Mr K Dunn regulation inspector completed the visit. The registered manager was not on site during the visit the deputy manager assisted the inspector with the inspection process. A tour of the premises took place and the inspector spoke to service users and viewed their bedrooms. Records were sampled as part of the inspection process including care plans, policies and procedures and employment records. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this site visit. What the service does well: What has improved since the last inspection? What they could do better: Thames Side DS0000013813.V330002.R01.S.doc Version 5.2 Page 6 There is still one outstanding requirement from the inspection of the 7th of November 2005 and the subsequent visit on the 25th of May 2006 “The service must ensure that staff receive formal supervision 6 times a year” at the point of this visit it was still unclear if any formal staff supervisions had taken place. The medication policy should be reviewed to ensure that the staff administrating medication do not deskill service users. The responsible individual should undertake a risk assessment on every individual to ensure that self-medicating is a skill that they can retain for themselves. 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.V330002.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 Thames Side DS0000013813.V330002.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): Standard 3 was assessed Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are undertaken prior to a potential service users moving into the service. It was evident that care plans were generated from these and therefore service users or their representatives can be confident that their needs will be met. The home does not provide intermediate care. EVIDENCE: The deputy manager stated that all potential service users receive comprehensive pre-admission assessments prior to service users moving into the home. The deputy manager further stated that this process is designed to ensure that the possible placement is suitable for the person and that there needs could be meet effectively by the home. A further component of the process is to determine the impact of the person moving in on the service and the existing service users resident at Thames Side. Two individual care plans Thames Side DS0000013813.V330002.R01.S.doc Version 5.2 Page 9 were sampled on the day of the site visit both demonstrated that the assessments process had been adhered to and fully completed. The deputy manager confirmed that the home does not provide any form of intermediate care. Thames Side DS0000013813.V330002.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): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users have individual comprehensive plans, they reflect the care, and support each person requires to maintain a valued lifestyle. In addition the plans fully detail the health care needs of the service users to ensure that they are fully met. The medication policies and procedures that are in place and are designed to protect the service users. The privacy and dignity of the service users is respected. EVIDENCE: Two individual care plans were sampled and they were found to contain detailed plans of care, risk assessments and daily notes. The deputy manager stated that the home has recently reviewed their system for documentation. Thames Side DS0000013813.V330002.R01.S.doc Version 5.2 Page 11 The deputy manager stated that every month the senior care staff update the plans and they then can be discussed and the service user. The inspector saw evidence of service user involvement and in some cases their representatives had also contributed. The deputy manager stated that service users have access to a local general practitioner (G.P.) who visits the home regularly. The inspector reviewed the medication policy; it was detailed and well developed paying great emphases on the health and wellbeing of the service users. The policy is readily available for all staff who are involved in the administration of medications. The deputy manager stated that she caries out an audit every month on the medication procedures. The inspector discussed with the deputy manager the need to ensure that appropriate risk assessments are completed on every service users to ensure that they can or cannot manage their own medication. In the event of the assessment indicating that the individual service users could self manage their medication every effort must be made by the service to ensure that they can maintain this area of independence. The deputy manager stated that the service is dedicated to the “notion of ensuring the privacy and dignity of the service users” and “to achieve this effectively a policy has been developed for the staff; this is then discussed with all new employees during their induction. In conjunction with the policies and procedures on privacy and dignity all staff have undertaken training in “Rights and Responsibilities”, which has been designed to instruct the staff team on their role in ensuring the service users receive a service that guarantees their privacy, dignity and promotes their diversity. The deputy manager also stated that the Rights and Responsibility training includes all of the elements of complaints and whistle blowing within the service. In order to maximise the privacy of the service users all bedrooms are for single occupancy they have en-suite facilities so personal care can be given there and visiting professionals can also consult in the privacy of service users own bedroom. Thames Side DS0000013813.V330002.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): 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. The service employees an activities organiser who provides activities, that are designed to match the expectation and needs of the service users. Family and friends are welcomed to the home whenever they want to visit and the service users are assisted to engage with the local community. Service users are assisted to exercise some control over their lives. The food at the home is of a good standard and meals are taken in wellappointed dining rooms. EVIDENCE: A programme of activities is available for all service users and is supervised by the activities organiser the inspector observed the timetable of event and activities. On the day of the site visit the inspector observed service users in one of the lounges attending a gentle game of softball. The object of the activity is to maintain some degree of flexibility and to improve hand to eye Thames Side DS0000013813.V330002.R01.S.doc Version 5.2 Page 13 coordination. The inspector observed the group who appeared to be very enthusiastic about the activity they were engaged in. Religious rights and services were observed and staff will ensure that if a service users wishes to attend a service that the appropriate arrangements will be made. Family and friends are welcomed to the home and the manager said there are no restrictions to the visiting time. It was also stated that all visitors to the home could see their relative or friend in private. The manager stated that service users are able to make choices in their daily lives. Service users stated that they are given a choice of meal and may choose the time they get up in the morning or go to bed. Observation of service users’ bedroom confirmed that personal possessions are permitted in the home. The inspector saw the tables laid in the dining rooms with tablecloths and napkins and juice or water was available. The service however does not have use of a vehicle that could cater for a large group of service users wishing to go out together and to make use of the excellent amenities found on this stretch of the River Thames. The deputy manager stated that when they organise outings they are heavily reliant on specialised taxi firms that have wheelchair provisions to enable the service users to access anything further that the local community. The deputy manager stated that “when a group of service users wanted to attend the theatre at Christmas the staff had to organise a series of taxies and cars to take them from the service to the performance”. It is recommended that the organisation reviews the transport arrangements at Thames Side and undertake a feasibility study on providing the service with its own transport. Thames Side DS0000013813.V330002.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): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users and their relatives understand that their views and complaint will be taken seriously, listened to and acted upon. Service users are protected from abuse the staff team have had additional training and demonstrated a clear knowledge of the procedures for safeguarding their welfare. EVIDENCE: During this site visit the home’s complaint policy was clearly displayed in the reception, the policy was service users focused and contained clear timescales for action. The manager keeps complaints log and all complaints no matter how small the issues may be perceived all complaints are given the same level of commitment to be resolved. The home has its own safeguarding adults policy, which is supplemented by the inclusion of the local authority policy on the protection of vulnerable adults. The deputy manager stated that all members of staff have now all received additional training in the local authorities procedures for safeguarding adults and they have also undertake the organisations own mandatory training in “Rights and Responsibilities”, which establishes their individual and corporate responsibilities in safeguarding service users and if necessary their expected actions as a “whistle blower”. Thames Side DS0000013813.V330002.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): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is maintained, decorated and furnished to a good standard and the facilities are safe and clean. EVIDENCE: A tour of the service took place the inspector observed a well-maintained environment, which provides aids and equipment to meet service users care needs. The individual bedrooms of the service users had been personalised by the person occupying the room. All bedrooms meet the national minimum standards and have their own private en-suite facilities. The communal areas allow service users to meet their relatives or friends in a variety of settings if they wish. Thames Side DS0000013813.V330002.R01.S.doc Version 5.2 Page 16 The grounds are still in need of attention and would benefit from the flower beds were cleared of weeds the introduction of bedding plants and spring builds being planted to introduce a more pleasant outlook for the service users. The laundry area was in good order and all sluicing machines were available for use. Service users laundry is collected in laundry baskets and washed individually and does not require labelling. Thames Side DS0000013813.V330002.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): Standards 27,28,29 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty and the skill mix was appropriate to meet service users assessed needs. Regular training (including national vocational training) takes place to ensure that a staff group that are competent to do their jobs assists the service users. Service users are protected by the home’s recruitment policy and procedures. EVIDENCE: There was sufficient numbers of staff on duty for the number and assessed needs of service users. The staff team on duty demonstrated an overall good skill mix. The deputy manager stated that she has some empty beds but that staffing numbers had not been reduced. The inspector looked at the rotas and found numbers were consistent to the pre agreed staffing levels. At the time of the site visit the staffing of the home consisted of two members of staff to ten service users in any one of the individual units. The deputy manager stated that in line with a requirement from the previous inspection report 25/05/06 50 of all care staff are now registered on a National Vocational Qualification Level 2 in Care (NVQ). In addition the deputy manager further stated that all team leaders are in the process of working towards their NVQ level 3 in care. The deputy manager assured the Thames Side DS0000013813.V330002.R01.S.doc Version 5.2 Page 18 inspector that all of the staff undertaking the NVQ level 2 or 3 should be completed in the next 3 or 4 months. The deputy manager had just completed a full audit of all staff files (15/03/07) and has introduced an employee file check list to ensure that all files contain the necessary information to safeguard the service users and in line with schedule 2 of the Care Homes Regulations (2001). The inspector sampled three recruitment folders. The home had all the necessary documentation required including two references, application form and any gaps in employment history had been explored. All applicants have had a criminal record bureau check prior to commencing employment. The deputy manager stated that all mandatory training takes place in house and this includes fire awareness, protection of vulnerable adults and manual handling. A record was sampled of all training that has taken place and indicated that the staff team individual and team needs are being effectively met by the services training policies. Thames Side DS0000013813.V330002.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): 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 overall management style in operation at the home creates an open and responsive environment. A quality audit of the service users, their representatives and further care professionals conducted by the service during January 2007, indicated the manager and his deputy are working in the best interests of the service users. Service user’s financial interests are safeguarded by the policies and procedures in place and adhered to by staff. The supervision of staff however continues to be a weakness of the service. The health and safety arrangements in the home ensure that the welfare of service users is promoted and protected. Thames Side DS0000013813.V330002.R01.S.doc Version 5.2 Page 20 EVIDENCE: The deputy manager stated that the manager has an open door policy, which allows service users and visitors to the home to see him at any time when he is on duty. In his absence the deputy manager is equally available as she was on the day of the site visit. The deputy manager also confirmed that the manger has now completed part of his NVQ level 4 and is planning to complete the full course over the next months. The deputy manager stated that the service holds regular service user meetings and relatives are also invited with minutes kept of the meetings. The most recent minutes were displayed on the service users notice boards they were reviewed by the inspector. The service had undertaken a full quality audit of the service users their representatives and visiting professionals the audit was conducted throughout January 2007. The completed forms had been collated and were seen as part of the inspection process. The general feedback received from the audit was of a high level of satisfaction with the service. It was however recommended that the manager reviews the questionnaire and to make it more users friendly and accessible to all the service users of Thames Side, the current format was very complicated and could easily confuse some service users. There has been no concerns expressed or instances of financial abuse reported and the policies and procedures in operations are robust, detailed and designed to protect the service users. There is still a considerable failure of the service to ensure that the staff team are offered formal supervision at least six times a year. The records reviewed during this visit indicated that in some instances some staff members have had only one supervision session in the last 12 months. This has been an issue, which has been picked up over the two previous inspections and was subject to requirements on the 7th of November 2005 and the 25th of May 2006. This was discussed with the deputy manger and it was recommended that she set diary dates for all staff trained to offer supervision and to set review dates to ensure that the service meets its expectations. The deputy manager stated that all health and safety checks are carried out regularly, certificates were in place and these included the electrical, gas and lift certificates they were made available on the day of the site visit. Thames Side DS0000013813.V330002.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 X 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 1 X X Thames Side DS0000013813.V330002.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? 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 OP36 Regulation 18(2)(a)1 2(5)(a) (b) Requirement The service must ensure that staff receive formal supervision 6 times a year. This was the third time this requirement has been made The initial timescale of 31/12/05 was not met and the service has failed to meet updated timescale 30/06/06. Timescale for action 28/04/07 Thames Side DS0000013813.V330002.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations It was recommended that the garden was weeded, lawns mowed and baskets and containers be prepared by staff and residents. It was recommended that the blanket policy for staff assisting with the medication of all service users be reviewed to ensure that the service is not reducing a skill that the individual could maintain. It is recommended that the organisation reviews the transport arrangements at Thames Side and undertake a feasibility study on providing the service with its own transport. It was however recommended that the manager reviews the questionnaire and to make it more users friendly and accessible to all the service users of Thames Side, the current format was very complicated and could easily confuse some service users. It was recommended that the manager sets diary dates for all staff trained to offer supervision and to set review dates to ensure that the service meets its expectations. 2. OP9 3. OP13 4. OP33 5. 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