CARE HOMES FOR OLDER PEOPLE
Thames Side Beldham Gardens West Molesey Surrey KT8 1TF Lead Inspector
Graham Cheney Announced 17 May 2005 11:00 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 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 H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Thames Side Address Beldham Gardens, West Molesey, Surrey, KT8 1TF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 89393850 Anchor Trust CRH Care Home 60 Category(ies) of DE(E) Dementia - Over 65, 26 registration, with number OP Old Age, 60 of places PD(E) Physical Disability - Over 65, 8 Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 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). 2. The age range of the persons to be accommodated will be: Over 65 years of age. Date of last inspection 1 February 2005 Brief Description of the Service: Thames Side is a purpose built residential care home to accommodate older people, it was opened January 2003. The home is sited in its own grounds with good size and well-maintained gardens, accessible to the service users. 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 ensuite 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. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection of Thames Side in the CSCI year 2005/2006, which started on 1st April 2005. It was an announced inspection, which meant that residents and staff knew that it was to take place. The main inspection was done by two inspectors who started at 10.00 a.m. and finished at 6.00 p.m. They were joined by a pharmacy inspector who looked at how the home took care of residents’ medicines. Normally only one inspector would visit, but the home had been through a difficult period and this inspection had been arranged to follow up on some of the problems that had occurred and check on the progress made. The two inspectors spent time with the acting management team to start with, then met with the chef manager. They then had a tour of the home and spent time talking with residents before having lunch with them. The rest of the time was taken looking at care plans, staffing arrangements and other documents and records. Residents and staff made the inspectors very welcome and were happy to talk about life at Thames Side. What the service does well:
Most of the residents who spoke to the inspectors were happy with the service provided. They said that they found the staff kind and helpful especially the regular staff. The home has had many staff changes and used a lot of agency staff recently, which meant that residents had needed to get to know many strange faces, which some said had not been easy. Residents said that they generally enjoyed the food and some explained that they were offered a choice of meals and could talk with the chef if they had any concerns. In the main they felt in control of their lives, but some found it difficult being reliant on others for support and going out. Many of the residents said they would like the option of more activities and this had been recognised by the staff and management. A volunteer had kindly taken on the job until a new person was appointed and was working with staff. All of the residents said they liked their rooms and especially having their own toilet. Some however did not feel it was as good as being in their own home. Most enjoyed having the company of others.
Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better:
The pharmacy inspector found that some prescribed medications, such as painkillers had not always been given and that there were some gaps in the medication records. Also some controlled drugs needed to be kept in a more secure cupboard. The home has care plans in place which provide details of each resident’s needs and wishes, these have not all been kept up to date as they should be and need to be looked at. A staff training programme needs to be set up to ensure that all staff have training opportunities and some of the regular staff can finish their NVQ. Staff files also needed to be reviewed to ensure they hold all the details of each member of staff.
Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 7 Information about the home needs to be looked at and up dated. Overall the evidence gathered confirms that significant improvements have been made to the way the home operates but this progress needs to be maintained. 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. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 5 Some minor shortfalls were found in the evidence gathered on this occasion, which meant that the standards assessed were not fully met. These will need to be looked at and updated to ensure that prospective residents have the information and opportunities to be able to make an informed choice about whether to move into the home and remain in control of their life thereafter. EVIDENCE: Information about the home, including the statement of purpose and service user guide, needs to be looked at and up dated. Residents care plans should provide evidence that appropriate pre admission assessments are undertaken and that there is evidence that prospective residents have the opportunity of visiting the home for a day prior to being admitted where possible. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 Evidence gathered from a review of care plans indicated that NMS 7 was not fully met. Although the shortcomings were minor, these must be addressed to ensure that residents’ needs and wishes can be consistently met. A review of medication handling was undertaken by a CSCI pharmacist inspector who concluded that that the systems for the administration of medication whilst safe could be improved. EVIDENCE: Medication stocks and records were sampled and showed that the majority of service users were receiving their medication as intended by their doctors. However an analgesic had not been available for one service user for 7 days and a further 5 service users had each not received a prescribed medication at some point during the last two weeks, as staff had failed to locate medication in the home. Whist the standard of record keeping was generally very high there were still some omissions in recording when medication had been given. Medication was stored securely for the protection of service users. However Temazepam tablets were not being stored in the Controlled Drugs inner cupboard. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 11 The home has care plans in place which provide details of each resident’s needs and wishes, these have not all been kept up to date as they should be and need to be looked at. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 With the exception of NMS 12 the evidence gathered indicated that these standards were fully met and therefore the home was supporting residents to maintain control and autonomy over their lives as far as they were able. NMS 12 was not fully met, which meant that some residents’ lives were not as fulfilling as they might be. EVIDENCE: Most of the residents who spoke to the inspectors were happy with the service provided. They said that they found the staff kind and helpful especially the regular staff. There had however been many staff changes and a lot of agency staff recently, which meant that residents had needed to get to know many strange faces, which some said had not been easy. Residents said that they generally enjoyed the food and some explained that they were offered a choice of meals and could talk with the chef if they had any concerns or particular wishes. In the main they felt in control of their lives, but some found it difficult being reliant on others for support and going out. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 13 Many of the residents said they would like the option of more activities and this had been recognised by the staff and management. A volunteer had kindly taken on the job and was working with staff. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Evidence gathered demonstrated that appropriate action was being taken to overcome the vulnerable adults concerns raised earlier in the year. On the evidence of this inspection both of these standards were now being met. This should mean that residents, their relatives and friends can have confidence that they will be listened to and have any complaints appropriately investigated. EVIDENCE: Residents and regular staff said felt that the home was running much better since the new management had started at the home. They said that they felt they were being listened to and supported. Anchor and the home’s new management team have taken action to rectify the vulnerable adults concerns and continue to address those concerns. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 26 Being a relatively new and purpose built home these standards were not considered to be of high priority on this occasion. On that basis all of the assessed standards were met. The home provides a high standard of accommodation for its residents. EVIDENCE: All of the residents said they liked their rooms and having their own toilet, although some did not feel it was as good as being in their own home. Most enjoyed having the company of others. The home was observed to be clean and well maintained. The manager’s office door was indicated to be a fire door, but was being retained open by an ornament. It was recommended that this be risk assessed. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The evidence gathered indicated that a good level of improvement has been made in respect of these standards, however none of them was considered fully met on this occasion, with ongoing work in progress. EVIDENCE: Most of the residents who spoke to the inspectors were happy with the service provided. They said that they found the staff kind and helpful especially the regular staff. The home has had many staff changes and used a lot of agency staff recently, which meant that residents had needed to get to know many strange faces, which some said had not been easy. The care staff rosters showed a reduction in the number of agency staff being used and there was evidence of new staff recruitment. A staff training programme needs to be set up to ensure that all staff have training opportunities and some of the regular staff can finish their NVQ. Staff files also needed to be reviewed to ensure they hold all the details of each member of staff. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 The evidence gathered indicated that a good level of improvement has been made in respect of these standards and on this occasion they were considered to be met. EVIDENCE: Anchor who own the home have appointed a temporary management team, made up of staff from other Anchor Homes, with the expectation that permanent appointments will follow. This follows the departure of the former manager and a very difficult period for the home. Findings on this inspection indicated that a good level of improvement has been made, with indications that the progress will be maintained. The new management staff have considerable experience working elsewhere as a manager and deputy.
Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 18 Residents and regular staff said felt that the home was running much better since the new management had started at the home. They said that they felt they were being listened to and supported. Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 x x 2 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 x 3 x x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x x x x Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 20 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 OP9 Regulation 12(1)(a) Requirement Service users must not be left without access to medication prescribed for them by their GP. Systems must be put in place by the provider to ensure that medication is available to the service users. Complete and accurate records of all medication administered to service users must be kept. When variable doses of medication are prescribed a record must be made of the actual dose administered to the service user. Information about the home needs to be looked at and up dated. The home has care plans in place which provide details of each resident’s needs and wishes, these have not all been kept up to date as they should be and need to be looked at. A staff training programme needs to be set up to ensure that all staff have training opportunities and some of the regular staff can finish their NVQ. Staff files also needed to be Timescale for action 06/07/05 2. OP9 17(1)(a) 06/07/05 3. 4. OP1 OP7 4, 5, 6 12(1)(a), 15(1)(2) 06/07/05 06/07/05 5. OP30 18(1)(a) 06/07/05 6. OP29 18 06/07/05
Page 21 Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 reviewed to ensure they hold all the details of each member of staff. 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 OP9 Good Practice Recommendations It is strongly recommended that ALL Controlled Drugs, including Temazepam, are stored in a Controlled Drugs cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The manager’s office door was indicated to be a fire door, but was being retained open by an ornament. It was recommended that this be risk assessed. 2. OP24 Thames Side H58_s13813_Thames Side_v214752_170505 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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