Inspection on 28/02/07 for Theobald House

This inspection was carried out on 28th February 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

Theobald House 14/11/05

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 Jeffrey Orange Key Unannounced Inspection 28th February 2007 08:00 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.V331117.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. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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.V331117.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 14th November 2005 Brief Description of the Service: Theobald House is a large detached two-storey property, which has been converted for use as a care home. The home, which is owned by Peaceknoll Ltd., is managed by its owner manager and was first registered in March 1985. 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 large and easily accessible garden to the rear of the property including a sheltered patio area. There is ample off street parking. The house is within walking distance of local shops, restaurants and pubs, with a local bus service and the railway station close by. Copies of the latest inspection report are available in the home, together with copies of the Service User’s Guide that includes contact details for the Commission for Social Care Inspection (CSCI). Weekly fees are £480; this is due to be reviewed in April 2007. Additional charges apply for personal toiletries, newspapers, chiropody, dentistry and hairdressing. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from early morning to early afternoon and provided an opportunity to meet service users and staff and to inspect key records, including those for the administration of medication and care plans. A brief tour of the premises was also undertaken. In the absence of the registered manager it was not possible to access certain records, however with the very able co-operation of the senior member of staff present, it was possible to obtain the necessary information to enable an informed view to be taken of the home’s operation. This report also draws on any information received by the CSCI since the previous key inspection in November 2005. What the service does well: What has improved since the last inspection? Any requirements made following the last inspection have been met. The maintenance of the previously assessed high standard of care found during the last inspection is in itself an achievement. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Theobald House DS0000019593.V331117.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 Theobald House DS0000019593.V331117.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): Standards 1 & 3 (Standard 6 does not apply to Theobald House). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information provided by the home to prospective service users and the assessment process undertaken prior to admission should ensure that only those whose needs can be appropriately met are admitted. The Service User Guide requires some minor amendments to ensure it is up to date and complies with recent revisions to the Care Homes Regulations. EVIDENCE: Several service users have become permanent residents following various periods of respite care. The pre-assessment information seen was sufficiently comprehensive to ensure that prospective service users needs are both identified and can be met. The home’s Service User’s Guide contains out of date contact information for the CSCI and does not yet take account of recent changes to regulation 5 of the revised Care Homes Regulations 2001. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users care needs are identified, monitored and reviewed to ensure that they are being adequately met. Care is provided by a dedicated and welltrained staff team who ensure that service users dignity and privacy are recognised and respected. Whilst the home has satisfactory policies and procedures for the administration of medication, attention needs to be given to the temperature of medication storage in the home and care taken to ensure that the highest standards of recording are maintained at all times. EVIDENCE: Care plans seen were well completed, contained the basic information required and had evidence of both regular review and the involvement of service users. Care plans included good evidence for the appropriate involvement of a range of health care professionals in order to meet the healthcare needs of service users. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 Page 10 “The carers are wonderful, nothing is too much trouble for them” this comment was borne out by observation of staff/service user interaction throughout this visit. The storage temperature of medication in the home exceeded the manufacturer’s recommended levels at the time of this inspection. Two errors were found in the record and/or reconciliation of service users medication balances. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities, food and social contacts meet service users needs in a way that appears to generate a high degree of service user satisfaction, without the existence of many formal mechanisms for ascertaining or recording choice. EVIDENCE: “It couldn’t be better” was a very typical comment and there were only varying degrees of praise for the standard and quality of the food in the home from service users. There are some basic records kept of activities undertaken, these are very informal, in line with service user’s moods at the time, and do not follow a set pattern. Menus are very basic, although it is understood that alternative choices are available. The long serving catering staff pride themselves on their knowledge of the individual needs and preferences of service users and meet these without a formal system of recording choice being evident. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 Page 12 None of the service users spoken with knew what they were going to have for lunch on the day of the inspection, although they all said that whatever it was would be good! Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has satisfactory policies and procedures for dealing with any complaints although most complaints, concerns or grumbles appear to be dealt with informally at an early stage, without being formally recorded. Staff receive training in the identification of abuse and the action to take if it is seen or suspected and this should ensure that service users are protected from potential abuse, neglect or harm. EVIDENCE: Complaint records were seen, with the last formal complaint recorded in December 2001. Staff spoken with all confirmed that they had received safeguarding vulnerable adults training and had a good understanding of issues around abuse and the appropriate action to take in the event that it is suspected. At least five service users spoken with asserted that they had “no complaints”. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 24 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and comfortable environment for service users, with the overall feel being homely and non-institutional. Some communal areas of the home do now need attention in order to maintain an acceptable standard. EVIDENCE: Service user’s rooms, seen with their permission, were comfortable and were furnished and personalised to reflect the interests and taste of the individual service user. The home was clean and tidy, with no problem arising from odour found on the day of this visit. The main lounge carpet and some corridors need replacement or redecoration where they are worn or marked. It is understood that the lounge has been Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 Page 15 identified for refurbishment in the near future and this will be monitored at the next inspection. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to retain a very stable, experienced and well-trained staff team who are well supported in order to meet the care needs of service users. EVIDENCE: All staff spoken to were very positive about the experience of working in the home, and the effectiveness of the staff team was confirmed by conversations with service users. Due to the absence of the manager, it was not possible to inspect recruitment records, however, the recruitment practice of the home has previously been found to be robust, providing confidence to service users. Staff confirmed that a range of training is undertaken, and NVQ training in particular is promoted. Supervision and team meetings take place appropriately and because this is such a settled staff team, they have an excellent knowledge of individual service users and their care needs. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 33 35 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and promotes the best interests of service users, based on an individual approach to their needs. Much consultation with service users is informal in nature, however care outcomes are consistently good. The home does make use of quality assurance surveys on a routine, regular basis, in order to monitor the quality of its service. EVIDENCE: The manager was not present during this inspection. However, in her absence the home was functioning effectively and efficiently. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 Page 18 All staff and service users were very positive and complimentary about the way that the home is managed and the support staff and service users receive from the registered manager. Quality Assurance survey forms were seen from September 2006, all were very positive and included comments such as; “It’s a wonderful home” and “Couldn’t be better”. The standard of record keeping was, in general, good. It is understood that the home does not hold monies on behalf of service users, who either deal with financial matters themselves or they are dealt with by relatives or representatives. Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X 3 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 X X 3 Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 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 Standard OP1 Regulation 5 Requirement The home’s Statement of Purpose and Service User Guide must be reviewed and amended as necessary to ensure it is accurate and up to date and meets the requirements of the Care Homes Regulations 2001 as revised. The registered person must monitor the temperature of medication storage in the home and take appropriate action if it is found to exceed recommended levels specified by the manufacturers in each case. The registered person must ensure that medication is consistently administered and recorded accurately. The registered person must assess the condition of carpets and decoration in the home’s communal areas and take appropriate action to ensure that they are replaced or redecorated where indicated by that assessment Timescale for action 30/05/07 2 OP9 13(2) 28/02/07 3 OP9 13(2) 28/02/07 4 OP19 23(2) 30/08/07 Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 Page 21 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 OP14 Good Practice Recommendations The way that choices for service users, for example over food and activities, are offered and if necessary recorded, should be reviewed, to make sure that service users are aware of the full range of alternatives available in each case. The procedure for the definition and recording of complaints should be reviewed to ensure that, without making the process unnecessarily onerous, it enables any trends or patterns to be identified by the home’s management. The registered person should ensure that risk assessments are in place for any first floor windows not fitted with opening restrictors and any radiators not covered or not of a low surface temperature specification. 2 OP16 3 OP19 Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Theobald House DS0000019593.V331117.R01.S.doc Version 5.2 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!