Inspection on 14/11/05 for Theobald House

This inspection was carried out on 14th November 2005.

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

Theobald House 28/02/07

Theobald House 06/07/05

Theobald House 30/09/04

Theobald House 11/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Theobald House 75 Theobald Street Borehamwood Hertfordshire WD6 4SL Lead Inspector Mrs Jan Sheppard Unannounced Inspection 14th 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 Theobald House DS0000019593.V264185.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. Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Theobald House Address 75 Theobald Street Borehamwood Hertfordshire WD6 4SL 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) 0208 953 1798 0208 953 0986 Peaceknoll Limited Ms Maria Philips Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 Brief Description of the Service: Theobald House is a large detached two-storey property, which has been converted for the use as a care home. The original house built in the 1930s has been extended to provided a total of twelve bedrooms, eleven single and one double. The ground floor comprises an entrance lobby and hall, a dining room, a lounge, a smaller lounge library room, 5 single bedrooms, the kitchen, the laundry room, a staff room, a storeroom and an assisted bathroom and toilets. Seven bedrooms, 2 bathrooms (one assisted) and the office are located on the first floor. There is a very pleasant and easily accessible garden to the rear of the property, which includes a sheltered patio. To the front there is ample off street parking as well as a garage. The house is within walking distance of the local shopping facilities, restaurants and pubs and there is a local bus service and the railway station is close by. The home, which is owned by Peaceknoll Ltd., is managed by its owner manager and was first registered under the 1984 Registered Homes Act, in March 1985. It provides comfortable homely accommodation and care for its elderly residents in a safe and secure environment. Theobald House DS0000019593.V264185.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 unannounced inspection of this inspection year and took place over one day when one inspector-spent time talking with the residents with all the staff on duty examined the care plans and other documents and made a tour of the building. The detail in this report reflects the findings at that time; being the second inspection of the year not all of the standards were covered on this occasion as they were all examined during the last inspection (on 6th July 2005) to which reference may be made. On the day of this inspection the home had a peaceful and well-ordered atmosphere. The residents looked to be well cared for and appeared to be happy and relaxed. It was noticeable that they all had very good rapport with their carers to whom they were making their wishes and requests known and that there was warmth and friendliness between the residents themselves. No new residents have been admitted to the home since the last inspection. What the service does well: What has improved since the last inspection? Since the last inspection a number of works of refurbishment, redecoration and the provision of new furnishings have further enhanced the appearance and comfortableness of this home. Several new activities and outings have been arranged for the residents in accordance with their wishes and needs. Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 6 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. Theobald House DS0000019593.V264185.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 Theobald House DS0000019593.V264185.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): 3 The home provides adequate information so that prospective residents are able to make a realistic and informed decision about admission. The manager makes an assessment of the care needs of all prospective new residents before inviting them to visit the home. Standard 6 is not applicable, as the home does not offer intermediate care. EVIDENCE: There have been no new admissions to the home since the last inspection. The most recent resident who was admitted to the home during May 2005, told the inspector that she remains very happily settled in the home. ”I have no complaints whatsoever”, she said and my daughters are also very pleased with the home”. Theobald House DS0000019593.V264185.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. The individual care and health needs of the residents are met in a manner, which maintains their dignity and respect. Personal care is offered by qualified and experienced staff. Care plans are comprehensive and are reviewed regularly ensuring that changes to health and social needs are recognised and met promptly. EVIDENCE: The care plans examined were found to have been well maintained and to be regularly reviewed. Where possible residents were seen to have signed their own plans and it was clear from the records that relatives were routinely invited to participate in the six monthly care plan reviews. District nurses notes were seen to be kept alongside the homes own planning records. Many files were seen to contain details concerning end of life care and funeral arrangements. More detailed records could be made of the activities undertaken by the residents. The home continues to benefit from the services of a retained GP: this ensures that their changing health needs can be promptly met. Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 10 The home continues to use the MDS, monitored dosage system for medication. This is supplied by a local pharmacist who visits regularly to audit the system. The MAR sheet records examined were found to be well kept and accurately recorded and the dates of the managers management checks of the accuracy of these records could be evidenced. Medication that is kept in the fridge should be stored in a lockable metal container. Theobald House DS0000019593.V264185.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): 12,13,14 and 15. The home provides a range of activities, choices of menu and alternative relaxation areas and encourages participation in the home by the local community. EVIDENCE: The home is able to accommodate each residents individual preferences for activities into their daily life routines. Staff were seen during the mid afternoon and teatime period, to be anticipating the wishes of various self selecting groups of residents for various activities. One group, several of whom were reading newspapers, were heard to be discussing various national news items. Another group commenced a singsong, which the inspector was told was a popular afternoon activity that usually arose spontaneously but was always helped by one carer with a particularly fine voice. One resident told the inspector of his daily activity of taking a walk in the garden for which he was always assisted by a staff member if needed. He remarked ruefully that his purpose in doing this with such regularity was to try to control his waist line”. The meals here are just so good I am finding this very difficult to achieve,” he said. The homes records evidenced that various outside entertainment and musical sessions are still provided several of the residents spoke of the recent visits of the choirs and a musical group from a local school. Since the last inspection several of the residents have enjoyed being taken to a local cinema to see a Jane Austin film. Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 12 Another similar outing was planned for the next weekend to which a meal out had also been arranged. One male resident told the inspector that he would like more visits to the cinema especially to see old war films. Several other residents told the inspector of the recent enjoyable evenings they had spent celebrating St. Georges and St Patrick’s Days. The recordings on the residents care plans do not adequately reflect the range of activities that are offered or are undertaken by each resident, and this recording should be expanded. Without exception all the residents were very complimentary about their meals. One resident told the inspector, “ The food here is smashing and it’s the same high standard every day!” The cook regularly sits in the lounge and discusses new dishes and choices with the residents and being small home individual dishes are frequently provided to meet individual wishes. One resident who does not like sausages, which are otherwise a popular choice in the home, is given an alternative choice of a chop or a steak, which he enjoys. The cook continues to hold separate menu cards for the residents breakfast choices these are completely varied, as is the time and location where breakfast is taken, either in their rooms or in the dining room. Detailed notes as to how breakfasts were to be served were also seen, i.e. ” please use Mrs.Xs china mug at breakfast time” Fresh meat and vegetables, much of it organic, is delivered to the home regularly and bowls of fresh fruit were seen in the sitting rooms and in some residents bedrooms. The recording of the menus should be more detailed to accurately reflect the variety and options of meals and snacks available. Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 13 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. The home has a complaints policy and procedure that meets the requirements of this standard. The home has policies and procedures concerning Adult Abuse and Whistle Blowing, which ensure that the residents are protected from abuse, neglect and harm. EVIDENCE: There have been no complaints or incidents concerning adult protection reported to the CSCI since the last inspection. A copy of the homes complaints procedure is given to all prospective and new residents and to their representatives. Staff spoken with demonstrated a good awareness of the issues surrounding Adult Protection and the guidelines issued by the Hertfordshire Joint Agency Consortium were seen to be displayed for the attention of all staff in the office. All staff attend training in this subject and several said that they had been studying this subject as part of their NVQ courses. Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 14 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, 25 and 26. The home offers pleasant safe and comfortable accommodation for its residents. It provides adequate space and facilities and a homely environment in which to meet their needs. The home is very clean and is well maintained following a planned routine maintenance programme. EVIDENCE: On the day of this inspection the home was found to be tidy, well organised and to have no unpleasant odours. Changes made since the last inspection to the floor coverings, and the replacement of some items of furniture in some rooms, have removed areas where odour previously lingered. The cheerful and varied decorations in the residents bedrooms, with colours and designs often chosen by them, provide a warm and homely ambience where residents were seen to have personalised their private spaces with their own items, small pieces of furniture, pictures and ornaments etc. All the residents confirmed that they were very happy with their rooms. Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 15 Refurbishment works in the kitchen have been completed to meet the requirements made during the last inspection. The exterior of the house is well maintained, as is the garden where a number of already flowering winter tubs were seen. Several of the residents discussed with the inspector the enjoyment they get watching the considerable variety of birds that regularly feed in the garden. During the afternoon of this visit six different bird varieties were counted. To ensure the safety of the residents at all times hooks in the first floor assisted bathroom, which are no longer used, should be removed from the wall. Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 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 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): 29 and 30 The home retains a very stable experienced and well trained work force, which on the day of this inspection were seen to be adequately meeting the care needs of the residents. EVIDENCE: The numbers of staff on duty were found to match the pre-planned staff rota. They were seen to be working well together as a team and to be anticipating and meeting the residents needs in a kindly competent manner. NVQ training is given a high priority in the home with several of the staff who have attained the NVQ level 2 now studying for the level 3 qualification. Since the last inspection the homes one vacant staff post, for a night carer, has been filled with an experienced worker who already holds the NVQ level 2 qualifications. The records evidenced that an induction training plan for this new staff member had already commenced. Theobald House DS0000019593.V264185.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): 31,33,37. This home is well run by its owner manager who is an experienced manager having for many years worked with this client group. She leads a stable and dedicated staff team and together they promote the best interests of the residents at all times. EVIDENCE: The manager communicates a clear sense of leadership within the home and promotes a sense of belonging to its residents. All the residents spoke well of her openness and approach to their care. One resident told the inspector, “ If you have a good leader everything follows on, I am very happy and well cared for here”. Another resident commented, speaking on behalf of a small group of residents sitting in the lounge, “ we are very well cared for nothing is too much trouble for the staff or the manager, we can talk to them about anything they make it very easy.” Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 18 The homes records are securely kept and those examined were found to be well maintained. Both sections of the CSCI Registration Certificate should be displayed in the Home. Theobald House DS0000019593.V264185.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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x 2 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x x 2 x Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 20 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. 2. 3 Standard OP37 OP9 OP19 Regulation S28 CSA 2000 13 (2) 13 (4) Requirement Both sections of the latest CSCI Registration Certificate must be displayed in the home. Medication kept in the fridge should be stored in a lockable metal container. Hooks in the first floor bathroom wall, which could pose a safety hazard, should be removed. Timescale for action 15/11/05 30/11/05 30/11/05 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 OP12 Good Practice Recommendations It is recommended that more detailed records are kept of the activities undertaken by each resident. Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Theobald House DS0000019593.V264185.R01.S.doc Version 5.0 Page 22 - 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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