Inspection on 18/05/05 for Thicket Road

This inspection was carried out on 18th May 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

Thicket Road 15/12/09

Thicket Road 15/08/07

Thicket Road 31/05/06

Thicket Road 03/01/06

Thicket Road 19/10/04

Thicket Road 30/04/04

Thicket Road 21/12/03

Thicket Road 14/08/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Thicket Road 79 Thicket Road Penge London SE20 8DS Lead Inspector Rosemary Blenkinsopp Unannounced 18 May 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Thicket Road Address 79 Thicket Road, Penge, London SE20 8DS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8659 8962 Leonard Cheshire Foundation Ms Susan Cornish Care Home 7 Category(ies) of Learning disability (7), Physical disability (1) registration, with number of places Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19/10/04 Brief Description of the Service: The home is a seven-bedded facility for those service users with a learning disability including one person with a physical disability. The service users in this home have challenging behaviour and need structured behaviour programmes and on-going support. Staff are provided throughout the 24-hour period. The home is a large detached house in a residential area of Penge. It is well served by public transport and close to local amenities. The home has undergone major refurbishment including a two-bedded extension on the lower ground floor. This has significantly improved the home for service users and staff. Policies procedures and documentation are generated through Leonard Cheshire Foundation with amendments made locally. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted as an unannounced visit. The inspection was combined with a complaint investigation. The complaint had been received and related to care practices, and the management of the home. The complaint was partially investigated by the inspector, whilst senior management of Leonard Cheshire will investigate the management issues. The inspector met with three staff two managers and residents. The information obtained from the residents was limited. No visitors or multi disciplinary team members had input into this inspection. A tour of the home was undertaken and records including a care plan, inspected. What the service does well: What has improved since the last inspection? The staff seemed to be working constructively with the residents and as a team. Systems for monitoring and supporting staff had been formalised. The management team has remained consistent for some time promoting more continuity in the service provided to residents. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 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. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: No standards were assessed in this section. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 The home promotes choice and addresses all identified needs in an individual manner. EVIDENCE: The care plan of the resident indicated in the complaint was inspected. General information was documented and a photograph in place. In addition assessment information and risk assessments were available. The care plan and associated risk assessment addressed activities of daily living including guidelines for addressing her care needs, administering medication and dealing with finances. The care plan relating to the residents’ communication abilities was not retained on file. This should be made available at all times particularly with the residents in this home and their difficulties in communicating. One lady has an advocate who is actively involved with her care, other residents have family members. Choice is limited only by the residents’ inability and identified risk assessment. Staff use makaton or prompting with use of objects to enhance communication. Staff were aware of the parameters of confidentiality. Please see requirement 1. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16,17. Within the limitations of the resident’s condition as normal a lifestyle as possible is promoted. EVIDENCE: Residents in this home are on specifically designed programmes, which cover aspects of daily living. All residents are supported by staff to under take their programme. Some of the activities incorporated into their programme included going out walking, attending day centres, shopping and in house activities. Three residents were out on their programmes as the inspector arrived. Recently, there have been some issues in respect of activities, in particular, how much residents were involved and had choice incorporated into their day. Greater staff monitoring has been implemented as well a staff rotation within the home. The menu was on display; previous menus and individual food monitoring forms were also inspected. The menu showed variation in the food offered daily, although no documented choice, the inspector was advised that the menu was designed around the likes of residents. The menu indicated various dishes including Italian, Chinese, and Indian as well as finger foods. Should a Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 11 resident not want the meal available staff would endeavour to offer a choice with use of prompts i.e. pointing to foods. A selection of foods was available as well as fresh fruit and vegetables. Staff in the home are developing a pictorial food menu as an aide with food choices. Some gaps were evident in the individual food monitoring forms. Audits carried out by the deputy manager had identified the omissions and new monitoring systems are now in place. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20,21 Residents receive appropriate support, including that from specialist teams, to address their personal and health care needs. EVIDENCE: The staff in the home are supported by the multi disciplinary team through the Bassett’s Centre. Psychology, speech and language therapists, doctors and nurses are all experienced with learning disability. Staff within the home and those employed through Bassett’s Centre, work jointly, at devising individual support plans. This was described as a good support service by staff in the home. Residents’ support was detailed in care plan documentation identifying not only the needs to be addressed but also the exact way in which they should be approached by staff. Where possible community health services are accessed such as the GP optician and dentist. Public transport is used where possible. Currently there are no residents who self medicate. The medication charts for the lower ground floor unit were inspected, and generally the information was completed, with the exception of one medication which needed more information detailed. Individual guidelines were in place to specifically advise staff on how medication should be administered. Please see requirement 2. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22. Complaints are actioned appropriately with supporting policies and procedures in place. EVIDENCE: The CSCI is currently investigating two incidents. The two complaints are being jointly investigated with the management of Leonard Cheshire. One incident is being investigated by the police with the CSCI. Complaints information was available and the procedure was on display. The staff should continue working with residents to maximise their understanding, particularly in the area of concerns and complaints. Staff with whom the inspector met were aware of whistle blowing and complaints procedures. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30, The home is suitable for the current resident group however it would be unsuitable in the event that any resident should suffer from mobility problems. EVIDENCE: The home has significantly improved over the last year. Redecoration of many areas, with new flooring and carpets, has greatly improved the home. Some areas are still to be addressed including an upstairs bathroom, which has been recently costed. Communal areas were clean and tidy both upstairs and downstairs. Curtains had been replaced with blinds or alternatives as these had suffered damage in the past. One ceiling was stained from a previous incident in the bathroom; this has been identified for redecoration. On the ground floor a new alarm system had been fitted as a health and safety measure for the resident. In the dining room there was some staining to the walls and skirting boards, which needs to be addressed. The front of the house was over grown and needs attention. Please see requirement 3. Bedrooms were individual in their colour schemes and presentation. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33 The staff team are sufficiently trained and supervised to meet residents’ needs whilst out of hours on call management provides additional support for staff. EVIDENCE: The off duty rota indicated that there are thirteen full time staff that cover the day and night period. Recently staff from the ground floor unit have been moved upstairs as concerns had been raised regarding their input with residents. This movement of staff has provided an opportunity to supervise and monitor staff performance more closely than was possible previously. Regular formal supervision systems are in place, conducted by the two senior staff. On call, out of hours support is provided by managers from Leonard Cheshire Homes. The inspector met with two staff on the ground floor unit and specifically asked them about the residents, their care and leisure needs, communication and food preferences. The staff members were aware of their support needs, communication issues and felt that they could identify when they were unhappy. One staff member did not participate in the discussion and really focused her time on the household tasks, which had been identified as an area of concern in the complaint. Some of the Hungarian staff have limited knowledge of this type of resident and are unfamiliar with care in the community. The management had identified the issues and further training, support and monitoring will need to be implemented to ensure that they are fully functioning in their role. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 16 Two staff have completed two units of the LDAF training and five others are due to start June 2005. All staff have the one day first aid whilst three have completed the four day course. Other recent training has included infection control, risk assessment and ongoing weekly training in sign language. Please see requirement 4. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,41,42 The manager is suitably experienced to run the home. Health and safety issues are addressed. EVIDENCE: The manager has worked in the home for three years and has completed her registered manager’s process through the CSCI. She is currently undertaking the Registered Managers Award, which she is due to complete July 2005. There was evidence of safe practice in respect of health and safety issues for example window restrictors, locked COSHH cupboards and first aid boxes in various locations. The service records were not inspected. Blue plasters were needed in one the kitchen first aid box and some cleaning products were not correctly stored on both floors. Please see requirement 5. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 2 x x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thicket Road Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 19 not checked 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 6 Regulation 15 Requirement The Registered Manager must ensure that all current information in respect of residents is available and accessible. The Registered Manager must ensure that all information in respect of medication is fully documented. The Registered Manager must ensure all areas are maintained including the garden The Registered Manager must ensure that staff have suitable skllls and knowledge to address residenst needs. The Registerd Manager must ensure that all health and safety measures are addressed Timescale for action 30/6/05 2. 20 13 30/6/05 3. 4. 28 32 23 18 30/9/05 30/6/05 5. 42 23 30/6/05 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. Thicket Road G51-G01 s6968 Thicket Road UI v211813 180505 Stage 4.doc Version 1.30 Page 20 Refer to Standard Good Practice Recommendations Commission for Social Care Inspection River House 1 Maidstone Road Sidcup DA14 5RH 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. 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