Inspection on 19/07/07 for Thetford Lodge

This inspection was carried out on 19th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Thetford Lodge 21/08/06

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Thetford Lodge 16 Thetford Road New Malden Surrey KT3 5DT Lead Inspector Adrian Gordon Key Unannounced Inspection 19th July 2007 10:00a 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 Thetford Lodge DS0000065234.V345988.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. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thetford Lodge Address 16 Thetford Road New Malden Surrey KT3 5DT 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) 020 8942 6049 020 8336 5831 CHD (Care Homes) Ltd Mrs Sue Martin Care Home 17 Category(ies) of Dementia (4), Old age, not falling within any registration, with number other category (13) of places Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2006 Brief Description of the Service: Thetford Lodge is situated in a residential street in New Malden, a short walk from the high street and close to shops and transport facilities. The home is a converted house with fifteen single bedrooms and one double bedroom. Accommodation is provided on the ground and first floor. The first floor is accessible by stairs and a chair lift. There is a small garden to the side of the home and parking is available. Information about the service is available in the Statement of Purpose and Service User Guide. Fees range from £372 to £600 per week dependant on the room and type of funding. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over the course of one day by one inspector. The inspection consisted of a tour of the premises, examination of records and observation of care practice. The inspector met with six residents, two visitors, three members of staff and the manager. Feedback questionnaires were received from one relative. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be improved in order to make sure that there is sufficient information on each residents social interests and background. New residents must also have a basic care plan in place on admission. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 6 There is still no annual development plan which was a requirement at the last inspection. This must be put in place to show how improvements will be made to the service. The practice of reducing training entitlement because of having had induction must cease. Training must be more consistent and sufficient so that all staff have the skills they need to carry out their role. 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. Thetford Lodge DS0000065234.V345988.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 Thetford Lodge DS0000065234.V345988.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): 1, 3, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are encouraged to visit the service before admission to make sure the home is suitable. Pre-admission assessments are carried out so that the service can be confident it meets each residents needs. EVIDENCE: Thetford Lodge does not provide intermediate care. The Statement of Purpose is up to date and contains good information about the service. The Service User Guide was seen to be in each residents room. Prospective residents are encouraged to come and visit the service, although if it is not possible a relative will visit instead. This was confirmed by two residents. The manager said she will visit people before they come to the Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 9 home. A pre-admission assessment is carried out to make sure that their needs can be met. This covers areas such as personal hygiene, social interaction and physical support. One person who has been at the home for a few weeks said they were very happy and had settled in well. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. There is good support in place to meet residents health needs. However, information on social interests and background must be improved. EVIDENCE: Care plans are clearly written and explain how needs are to be met in areas such as dressing, hygiene, mobility, diet and religion/culture. They are regularly reviewed and kept up to date. However care plan information must be more detailed. For example, the information for one resident stated ‘her friends visit’, but it did not explain who the friends are. Information on relationships, sexuality and life history must be included to give a clearer picture of each resident’s identity. Two care plans were signed but not dated. One person who had been at the home for two weeks did not have a care plan in place. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 11 Information in resident files helps staff to meet their health needs. Records are kept of visits to the dentist, optician and doctor and details of health professionals involved are made clear. Care plans explain how health needs are to be met. Moving and handling assessments are in place to ensure residents are moved safely and with appropriate support. Medication Administration Record (MAR) sheets were correctly filled in and there were no visible errors. Records have a photograph of each resident to prevent any errors. Allergies are also noted. A record is maintained of medication that is bought into the home or returned to the pharmacy. The Statement of Purpose states that all residents have the ‘right to have their cultural, religious, sexual and emotional needs accepted and respected’ and also the ‘right to privacy’. Staff were seen to knock on bedroom doors before entering and all doors can be locked from the inside. Staff were observed to treat resident with respect at all times. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents are able to take part in a good range of activities. Visitors are made welcome and can see residents at times that suit them. EVIDENCE: An activity programme for the week is displayed in the lounge. Ideas for the week include exercise, cake making, card games and a walk. A number of outings are planned in the summer months. Entertainers also come and visit, such as singers or musicians. A newsletter is now produced which explains more about upcoming events. Some residents attend a day centre. Family and friends are able to visit when they prefer. This was confirmed by relatives who were around at the time of the inspection who said they were made welcome. A phone is available if residents want to make use of it and some people have a permanent phone in their room. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 13 Menus show there is a good range of food available. A notice in the dining room shows what is on the menu for that day. The cook also goes round to each resident in the morning and asks what preference they have. Comments were generally positive about the food given in the week, but less so about weekends. One resident said that they are sometimes offered sandwiches which have been made the day before. Lunch was observed in the dining room. Residents were free to sit where they wanted and were nicely supported by staff. Tables were well presented with drinks on the table and napkins for people to use if required. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel safe and are aware of how to make a complaint. A lack of regular training in adult abuse awareness does not support staff in protecting residents. EVIDENCE: There have been no complaints since the last inspection. There have been a number of compliments from people about the care received by their relatives. Good procedures are in place which state that the person receiving the complaint must ensure that the resident must fully understand the outcome or decision taken. The procedures refer staff to the adult abuse policy if necessary. Thetford Lodge works to the Royal Borough of Kingston’s protection of vulnerable adult (POVA) procedures. Some staff took part in POVA training in March and April 2007. However, not everyone has completed refresher training over the past year. The manager said that this has been planned. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in a homely and pleasant environment. EVIDENCE: Thetford Lodge is laid out over two floors and has a pleasant feel throughout. On the ground floor is the main lounge and separate dining area. These were both bright, clean and well furnished. Photos of residents and pictures on the wall make it homely and personalised. There is a small rear garden area with seating and a gazebo. The kitchen was clean and well maintained but would benefit from having a new extraction fan. The majority of bedrooms are located upstairs. Four bedrooms were seen and these contained personal possessions such as pictures and items of furniture. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 16 Residents spoken to said they were happy with their rooms. Bedrooms are lockable from the inside and residents hold a key. All parts of the home were kept clean and clear of obstacles. Communal areas and bathrooms were odour free. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 competent staff team provides good support to residents. However training must be more consistent and accessible so that staff have all the skills they need to carry out their roles. EVIDENCE: The staff team has remained consistent over the past year. On the day of inspection the staffing levels were appropriate for the number of residents. This was confirmed by the rota. However, some staff felt that staffing levels were not sufficient for the amount of work to do. Staff morale is being affected by recent changes to terms and conditions and there was some discontent expressed about pay and training. Staff were observed to relate well with residents and to offer support sensitively, taking time to listen carefully to what was being said. Records of recruitment show that all the necessary checks are in place for staff. Criminal Records Bureau checks are carried out before employment, however some of these were over three years old. A risk assessment was in place for one person who had a caution on their disclosure. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 18 Staff are entitled to three days paid training each year. All staff have been reinducted following the purchase of the home by a new company. Induction is over five days. The provider has put in writing that ‘the employee will be paid to attend induction but one day worth will be removed from their training entitlement over the next two years of employment’. This does not support staff to gain skills suitable for their roles. Core training is planned over the next few months. Recent training undertaken by some staff includes Dementia Care, Challenging Behaviour and Fire Safety. All staff have recently been asked to sign a declaration agreeing to pay back a proportion of training costs if they leave within two years. This is clearly having a negative affect on staff morale. The provider should reconsider asking staff to pay for training that is essential for their jobs. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from an experienced manager who ensures there is effective monitoring of the service. EVIDENCE: The registered manager has been in charge for a number of years and has a very good understanding of each residents needs. She was seen to treat the people who live there with a great deal of dignity, humour and warmth. Staff said that they are supported by the manager to carry out their roles. On the day of inspection the manager said that she would be leaving in August 2007. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 20 Residents and their relatives are sent questionnaires as part of the quality assurance process. The most recent survey was at the beginning of June 2007. Ten responses were received from residents. These gave a mostly satisfactory response about living at the home. Four residents said they didn’t know who to speak to if they were unhappy. Evidence was seen that this was followed up and the residents were informed. An annual development plan must be put in place which outlines the strengths and weaknesses of the service, together with an action plan to make improvements over the coming year. There is a good system for monitoring resident finances. Records are clear and all transactions are signed for. The manager checks the accounts once a month. Receipts are kept for purchases but these must be numbered so it is clear which receipt refers to each entry in the account. One resident’s file held a financial risk assessment which supported them in maintaining financial independence. Health and safety checks are all up to date. Hazardous substances information is in place in case of accidents. This was reviewed in January 2007. The health and safety risk assessment is also up to date. Call bells are checked weekly to make sure residents can contact staff in an emergency. A visit from the London Fire and Emergency Planning Authority in April 2007 found no problems. Fire points are tested weekly, however when this is done it should be recorded which point has been tested. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 X X 3 Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 12(1) 15 Requirement Timescale for action 01/10/07 2 OP18 13(6) 3 OP30 18(1)(c) 4 OP33 24 (1) In order to make sure that all residents needs are fully met care plans must provide sufficient detail and include information on relationships, sexuality and life history. All care plans must be dated and all new residents must have a basic care plan on admission admission. To further protect residents all 01/10/07 staff must have yearly refresher training in the protection of vulnerable adults. To ensure that all staff are 01/11/07 supported in their roles core training in core skills must be provided. Induction must be provided in addition to regular training entitlements. To ensure there is more effective 01/11/07 quality assurance, an annual development plan must be put in place. This was a requirement at the last inspection. Timescale 01/11/06. Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 23 5 OP35 13(4)(c) To further protect residents financial interests all receipts must be clearly numbered and recorded. 01/10/07 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 OP30 Good Practice Recommendations In order to provide effective training and improve staff morale, the provider should reconsider the practice of asking staff to pay for training should they leave the home within two years. To make sure all points are tested in rotation, weekly fire point test records should show which point has been tested. 2 OP38 Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Thetford Lodge DS0000065234.V345988.R01.S.doc Version 5.2 Page 25 - 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. 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