Inspection on 07/11/05 for Thames Side

This inspection was carried out on 7th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 16/03/07

Thames Side 25/05/06

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 Damian Griffiths Unannounced Inspection 7th November 2005 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.V263821.R01.S.doc Version 5.0 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.V263821.R01.S.doc Version 5.0 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) Anchor Trust Miss Glenda Ann Edwards 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.V263821.R01.S.doc Version 5.0 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 17th May 2005 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. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of two to be undertaken in the Commission for Social Care Inspection Year April 2005 to March 2006. It was an unannounced visit and took place over a period of 7 hours. Lead Inspector Damian Griffiths was assisted throughout the inspection by the Manager (yet to be registered) Derek Purchase and Deputy Manager Lorraine Sewell representing the establishment. The Inspector sampled details of five residents care assessments and care plans and six staff files. Four residents, two of their representatives and three staff members were consulted The inspectors would like to extend thanks to the staff and management at Thameside for their assistance and hospitality. What the service does well: What has improved since the last inspection? The new manager has started to review all the residents care plans and has established along with the assistance of the deputy manager a good rapport with staff and residents. An activities co-ordinator has been employed and regular daily activities are now monitored to ensure that they are successful. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 6 Medication records inspected confirmed that residents were receiving the correct dosage of prescribed medication. A staff training programme had been set up to ensure that all staff have training opportunities and some of the regular staff can finish their NVQ. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 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.V263821.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. The Service User guide was in need of review to include details of staff. New and existing residents received a full assessment of their needs however contracts were not in evidence. EVIDENCE: The service users guide was in need of updating to include the name of the new manager, deputy manager and staff details. Five residents files were inspected and only one contained the resident’s contract. Assessments were contained on the residents files inspected. Each file contained a care manager’s assessment and a brief assessment completed by the home covering the main points of need. Please see the requirements section of this report Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7,8,9 and 10. Residents’ files did not contain care plans and they were in need of review but the residents did benefit from a radical innovation to improve their health care needs. Storage of unused medication was in need of improvement but staff provided care services that respected the privacy of the residents. EVIDENCE: Four residents files were inspected but did not containe care plans. Some contained partially completed risk assessments; medical assessments and activities preferred by the residents and were in need of review. The manager (yet to be registered) did acknowledge this and is endeavouring to rectify the situation. Thameside and the local Primary Care Trust and Social Services have made provision for a Nurse practitioner to work with the residents for 20hrs per week. The residents benefit from having regular health checks and staff have the opportunity of gaining a better understanding of the health care needs of the residents. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 10 The medication practice of one of the units was inspected. Medication was found to be securely stored in a locked cupboard. Two metal cabinets containing the residents’ medication were inside. Unused medication was discovered within the locked cupboard but not in the secure cabinet, there was no note of this recorded on the Medicine Administration Record (MAR) or a record of any drug returns in evidence. Resident’s photographs were attached to the MAR sheets and were all in order and all entries had been appropriately initialled by the staff. Controlled drugs storage is being reviewed due to the size of the existing storage area. The one resident being prescribed a controlled drug is having the prescription changed from blister packs to liquid for ease of consumption and storage in the controlled drugs cupboard. Residents their representatives were consulted and they confirmed that staff respected residents’ privacy. Staff were observed addressing residents by first name and knocking on the residents door before entering or as a relative commented saying ‘knock knock’ if the door was already open. Please see the requirement section of this report. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 12,13 and 15. Residents benefited from the activities available at the home and resident’s families’ friends were always welcome. Residents who were consulted during the inspection enjoyed meals. EVIDENCE: There was a full time activities co-ordinator available for residents at the home and lists of the available activities were posted on every unit. Residents consulted enjoyed playing scrabble; chess and one resident was knitting a ‘pom-pom’ used in various games on the unit. Family and Friends were welcomed at the home and this was confirmed by residents and representatives consulted during the inspection. Residents dined in their own unit and were all happy with the food provided. They can access the kitchen whenever they wish to make their own tea however staff were observed doing this during the inspection. Menus were available on the unit’s notice boards and corresponded with the meals being served. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 16 and 18. Complaints and protection of residents from abuse policies and procedures were in place and in operation. EVIDENCE: Residents and relatives consulted were happy with the complaints system in place however another resident did not know who to complain to if they were not happy. The complaints book contained three complaints that had been satisfactorily resolved. Protection of vulnerable adult procedures were evident with copies of Surrey’s Multi-Agency Procedures in evidence. The staff handbook contained reference to the whistle-blowing procedures and staff were aware of policy. There had been one recorded vulnerable adult investigation since the last inspection and the home had followed the Multi-Agency procedures. Residents have the option of having their own front door key and there were lockable draws in all rooms for personal belongings. There is also an office safe available if residents require additional security. Residents consulted stated that they felt safe and well cared for. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19,20,21,24,25 and 26. Residents enjoy a spacious and purpose built environment that was pleasant, light and airy. The rooms were generally clean, personalised and clearly reflected personal needs. Bathrooms and communal toilets were clean and well stocked. There were areas however in need of refurbishment. EVIDENCE: A tour of the premises took place and the home was found to be clean, tidy and there were no offensive odours detectable or obvious hazards to health and safety. Residents have safe access to lounge areas: corridors leading to comfortable window seating, the kitchen and dining area if required. Lifts access the two floors and there is a fenced garden that surrounds the premises. The communal toilets were in good order clean and well stocked with toilet rolls and paper towels all were wheelchair accessible. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 14 Resident’s bedrooms clearly reflected their personality and preferences with good quality furniture in evidence. Other residents’ rooms reflected their hobbies and interests and required the homes assistance to continue with these pursuits. Some resident’s carpets were in need of cleaning or replacement and one resident required a health and safety check of electrical equipment. Some of the rooms inspected would benefit from some minor redecoration. The homes manager informed the inspector that he was preparing a review of decoration and refurbishment The laundry area was in good order and all sluicing machines were available for use. Resident’s laundry is collected in laundry baskets and washed individually and does not require labelling. This system works well but at times laundry can get lost when soiled laundry is placed in the ‘sluice bags’ to ensure infection control is observed. The bags are not always labelled and clothes can get misplaced. Please see the requirements section of this report. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. The recruitment procedures were in place but were at risk of compromise by the use of agency staff without proof of skills. There was adequate training available for Thameside staff, however, the manager needs to ensure that staff have adequate skill mix to ensure residents safety at all times. EVIDENCE: Staff rotas were inspected to see if staff were adequately trained to offer a good skill mix to residents throughout the day. The night shift rota showed that agency staff were represented but there was no record available to support the adequacy of their training or qualifications. It is essential that staff have a skill mix that includes knowledge of first aid, fire, and safe manual handling and medication administration. Six staff files were inspected and recruitment policy and practice was inspected. Four files were incomplete and did not contain the required documents as listed in Regulation 19 schedule 2 of the Care Homes Regulations (2001). Training was available and included all core skills to ensure resident were well cared for and safety was maintained: Safe Handling of Medication, Safe Manual Handling, Food Hygiene, Infection Control, First Aid, Fire Safety and Health and Safety. A training programme had been put in place and Anchors own internal assessor will assess staff for their NVQ. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 16 Pressure sore, epilepsy and diabetes training was available to staff and regular updates due to the provision of a nursing practitioner at the home. Please see the requirement section of this report. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,37 and 38. The manager (yet to be registered) has a good staff team and works well with meeting his responsibilities. Regular residents meetings were available and consultation by representatives of the Anchor group had taken place. Staff were in need of regular formal supervision. The health and safety of residents was generally well managed however there were identified risk assessments in need of completion. EVIDENCE: The new management team have made an impressive start with the reviewing of residents care needs and updating records. There was evidence of a recent ‘Care Review’ showing support and acknowledgement of the need to review care practices from the Anchor Area Office. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 18 Residents views were sought every month as part of the regulation 26 visits and residents meetings were also available monthly. Residents stated on the comment cards that they were satisfied with their level of involvement. Measurable quality assurance monitoring is overdue and must be completed. The health and Safety of Policies and procedures were all in place including RIDDOR, COSHH and insurances and certificates as required. The extractor hood over the hob in the main kitchen area was in need of cleaning. This was brought to the attention of the manager (yet to be registered) who confirmed that a steam clean contractor has been booked. There was no recent report available from the Environmental Health department as required. A resident with a large accumulation of electrical equipment required regular risk assessments, as he had accrued three mugs of tea that had not been drunk were found on a table above a ‘multi-plug’ fixture. The cups were removed immediately. Please see the requirements section of this report. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 2 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 2 2 Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 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 OP1 Regulation 4, 5, 6 Sched 1 5 sched 4 para 8 12(1)(a), 15(1)(2) Requirement The service must ensure that information about new staff and staffing must be available in the service users guide. The service must provide a contract of residency the details fees, terms and conditions that is available to the resident. The service must ensure that the home has care plans in place, which provide details of each residents needs and wishes, risks assessed and what actions required. This is the second time this requirement has been made. A new timescale has been agreed. The service must ensure that there is a complete and accurate record of all stored medication and the drug returns book is available for inspection. The service must ensure that all parts of the home are kept clean and reasonably decorated and consider whether new carpets are required. The service must ensure that DS0000013813.V263821.R01.S.doc Timescale for action 31/12/05 2. OP2 31/12/05 3. OP7 31/12/05 4. OP9 17(1)(a) 31/12/05 5. OP24 23 31/12/05 6. OP27OP28 18(a) 31/12/05 Page 21 Thames Side Version 5.0 7. OP29 19(c) 8. OP29 18 9. OP31 9(2)(i)(ii) Schedul 2 10. OP33 24 11. 12. OP36 OP37 18(2)(a) 12(5)(a) (b) 17(1)(a) 13. OP38 13(3)(4) (a) suitably qualified and trained staff are available at all times and that agency staff receive full induction training. The service must ensure that staff recruits provide the information required and listed in schedule 2 of the Care Homes Regulations 2001. Staff files also needed to be reviewed to ensure they hold all the details of each member of staff. This is the second time this requirement has been made. A new timescale has been agreed. The service must ensure that manager provides details of enrolment and a timescale for completion of the NVQ 4 management/care award. The service must supply to the Commission with a quality assurance report in respect of the quality of care. Residents, their representatives and Care practitioners must be consulted and a copy of the results to be made available to them. The service must ensure that staff receive formal supervision 6 times a year. The service must maintain, update and review all records relevant to the efficient running of the care home and ensure the health safety and welfare of the residents. The service must ensure that the health and safety of the residents is protected by: arranging regular inspections from the environmental Health department, regular environmental risk assessments and electrical equipment checks. DS0000013813.V263821.R01.S.doc 31/12/05 31/12/05 31/12/05 31/03/06 31/12/05 31/12/05 31/12/05 Thames Side Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2. Refer to Standard OP12 Good Practice Recommendations Provide special jigsaw puzzles mats that allow residents to store the puzzles when they are still incomplete and to save space. Thames Side DS0000013813.V263821.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office 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 © 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.V263821.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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