Inspection on 03/01/06 for Thicket Road

This inspection was carried out on 3rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thicket Road 15/12/09

Thicket Road 15/08/07

Thicket Road 31/05/06

Thicket Road 18/05/05

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 Miss Rosemary Blenkinsopp Unannounced Inspection 3rd January 2006 10:00 Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 Adults 18-65. 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. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thicket Road Address 79 Thicket Road Penge London SE20 8DS 0208 776 9569 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) Leonard Cheshire Ms Susan Cornish Care Home 7 Category(ies) of Learning disability (7), Physical disability (1) registration, with number of places Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 Brief Description of the Service: The home is a seven-bedded facility for those residents with a learning disability including one person with a physical disability. The residents in this home have challenging behaviour and need structured behaviour programmes with on-going support. Staff are provided throughout the 24-hour period with waking night staff. 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 DS0000006968.V275219.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted as an unannounced visit by two officers. The deputy manager facilitated the inspection. During the inspection the inspector met with two staff, one agency and one permanent member. A brief tour of the premises was undertaken. A selection of documentation, including risk assessments, care plans, medication charts and quality assurance measures were inspected. It was difficult to engage residents in the inspection process although signs of well being noted in residents’ behaviour and interactions with staff in the home seemed positive. Generally the findings of the day were satisfactory although some of the documentation needs to be reviewed. What the service does well: What has improved since the last inspection? What they could do better: The residents ‘care plan documentation was not maintained in an orderly manner and information not easily extracted. Some of the information retained on file was out-dated and not relevant to current needs. Any information which is not required, should be archived and safely stored. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 6 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 DS0000006968.V275219.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3,4,5. The Statement of Purpose does not currently accurately reflect the type of residents for whom it provides the service. EVIDENCE: The registration categories are currently under discussion, with a possible change from severe learning disability to mild/moderate learning disability. This has not yet been agreed. The Statement of Purpose will need to be amended to reflect this change if agreed. Included within the Statement of Purpose was reference to staff training although from documents inspected some of these were not being addressed as frequently as needed. This is further referred to under the staffing section. Within the resident’s folder were as a Social Services Review and needs assessment, a contract and Statement of Purpose. There was no photographs of the residents and no evidence that the manager had confirmed in writing to the residents, that having regard to the assessment, the care home is suitable for the purpose of meeting the resident’s needs in respect of his health and welfare as set out in regulation 14 (1.d). Please see requirement 1. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 the following standard(s): 6,7,9. Care plans and risk assessments are in place to address residents’ needs and generally reflective of their individual support. EVIDENCE: The inspector looked at two residents’ information folders during this visit. The files were found to be comprehensive, but not ordered; one was full of old and outdated paperwork making it difficult to read or find particular information. Monthly reports were evident and were mainly up-to-date. Included in the files were Action Plan Meeting notes and Action Plans drawn up from these meetings with time scales and progress records where progress on each individual action was monitored. They clearly showed that planned activities, a holiday, the redecoration and refurbishment of one resident’s room had happened within the expected time scales. This is good evidence that the residents’ continuing and changing personal goals are assessed and listened to. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 10 The risk assessments were inspected and found to be in order. An overall risk assessment was carried out for each resident and then detailed assessments were done for any areas of risk highlighted. Attached to each risk assessment were guidelines on how to carry out the involved action. The guidelines were detailed and it is recommended that this information be included in the resident’s care plan to enable support staff to have easy access to detailed knowledge of how to work with each individual. However there was no risk assessment carried out for the home’s newest resident. In view of the Care Manager’s assessment, highlighting areas in her history that show a need to have robust risk assessments, in place it is imperative that assessments are done immediately. There were also general house risk assessments in place. Some but not all of the risk assessments were signed and dated as reviewed. It is good practice to regularly review and update all risk assessments. Please see requirement 2. Please see recommendation 1. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 11 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 the following standard(s): EVIDENCE: No standards were assessed in this section. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 the following standard(s): 20 Medications are safely stored and supporting documentation reasonably completed. EVIDENCE: The medications were inspected on the ground floor. The medication cupboard was maintained in an orderly manner and all medications checked were in date. Medication charts had photographs of the residents and their individual allergies recorded. The procedure for medication administration was in place and supported by individual residents procedures. This supporting information gave specific information on how to approach the resident and administer medications. These had been updated April 2005. Individual “as required” medications were in place, which detailed when to use, maximum dose and frequency. These had been updated May 2004 and should be reviewed. Individual homely remedies for each resident were in place signed by the GP. These were dated in 1999 and 2000 and need reviewing. On the medication administration charts some entries were hand transcribed and the amount of medication received into the home had not been recorded. Please see requirement 3. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 the following standard(s): 22. Information and avenues by which to make a complaint are available however more information of the type that residents can access and understand should be explored. EVIDENCE: There is a complaints procedure available on display in the hallway of the home. Complaints made regarding the service are investigated by senior managers at Leonard Cheshire. One complaint investigation was conducted 2005; this was by the CSCI with assistance form Leonard Cheshire. The home retains information on complaints, including whether the complainant was satisfied wiht the outcome, the investigatory route and supporting documentation. There have been three complaints made in 2005 including the one referred to in the above paragraph. Staff were aware of when residents are unhappy, however, with the limited communication of some residents, it is difficult to extract information and identify actual complaints specifically. The home should explore other communication methods to enable residents to express any concerns or dissatisfaction. Please see recommendation 2. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 the following standard(s): 24. The home is well maintained, domestic in manner with safety features addressed. EVIDENCE: The home has made great steps in the environmental standards. Sitting and dining areas were maintained in a domestic manner. The ongoing maintenance has had a positive effect with all areas, including the garden. One bathroom has been replaced to a high specification vandal-proof style. Staff had worked hard to dress this bathroom, which is stainless steel and cold looking, and their efforts made the bathroom area look pleasant. The lower ground floor flat had been flooded and a ceiling had come down. This has been made good but full redecoration is awaited by Hyde Housing. No residents or staff were hurt when the ceiling collapsed. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 It was evident that some staff working within this home did not have sufficient skills and knowledge for the work that they undertake. EVIDENCE: The home has reviewed its staffing levels to provide senior staff in the home on all shifts. On-call support is offered via various tiers of management, through Leonard Cheshire. There are two agency staff who have worked for approximately four months in the home on a regular basis. One of the agency staff met with the inspector. It was difficult to extract information from this agency care worker. She was asked pertinent questions about care of the residents and specifically autism with challenging behaviour . She demonstrated a poor knowledge on these topics. The inspector asked her about the care of specific residents, again she demonstrated a poor knowledge of the individual needs and approach. She was unclear of COSHH guidance or specifically what action to take in the event of a fire. This was followed up with the deputy manager for action. A permanent staff member met with the inspector. She had been in post since 2002. She demonstrated a good knowledge of the residents’ individual needs and a reasonable knowledge of autism and associated needs. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 16 The inspector requested information in respect of the checks made on agency staff, including identification confirmation of CRB clearance and competency. At the time of the inspection this information was unavailable. Three personnel files were inspected of those permanent staff most recently recruited. The three staff were from overseas. The general content was to a good standard with medical information, photographs and identity checks, CRB and POVA clearance. On all files the inspector was unable to locate references. There was information relating to college courses, although not formal references. These need to made available and on file. The inspectors were advised that three staff had passed the induction and foundation of the LDAF training, whilst three staff had completed the induction. Four staff are due to start the NVQ 2 in April 2006. There were training records for each staff member that also included identified training needs and future planning. The training recorded included Basic Food Hygiene, First Aid, Health and Safety awareness and Protection of Vulnerable Adults. Training certificates in staff records confirmed this. There was no evidence, except that which is stated above, indicating that there had been any training specific to this resident group, such as awareness of autism and epilepsy or dealing with difficult, aggressive or challenging behaviour. The assistant manager assured the inspector that regular in-ouse training was given, in these areas, but that it is not recorded on the training records. It is recommended that all training be documented. Please see requirement 4 and 5. Please see recommendation 3. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Residents are involved, as much as their disability allows to participate, in service developments. EVIDENCE: The first aid boxes were in need of replenishing although the deputy manager stated that this was in hand. Regulation 26 visits are conducted monthly. These were inspected and it was noted that these were not always conducted by the Registered Provider or another director responsible for the management, as detailed under Regulation 26 (2). Residents are involved in some aspects of the daily running of the home including menu planning, redecoration and refurbishment of their own areas. Each resident has a key worker and a medical consultant based at Bassett’s Centre with on going multidisciplinary input. Families are invited to all multi disciplinary reviews. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 18 Staff have attempted to initiate a relatives’ meeting although this proved unsuccessful with no-one attending the last one. Two resident have independent advocates. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 19 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 Standard No Score 1 2 2 2 3 2 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 2 X X X X Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 20 Yes 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 YA3 Regulation 14 Requirement The Registered Manager must ensure that they confirm in writing, following their own assessment, the home’s ability to meet their needs. The Registered Manager must ensure that risk assessments are in place for all residents, specific to needs, kept under review dated and signed. The Registered Manager must ensure that all information relating to medication is recorded and homely remedies are reviewed regularly. The Registered Manager must ensure that all staff, including agency workers, are suitably trained for the work that they do. This is now outstanding previous time frame for action 30/6/05. The Registered Person must ensure that all information relating to staff recruitment is available on file. Timescale for action 31/03/06 2 YA9 13 30/01/06 3 YA20 13 30/03/06 4 YA35 18 30/03/06 5 YA34 19 30/03/06 Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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 2 3 Refer to Standard YA7 YA22 YA35 Good Practice Recommendations The Registered Manager should ensure that all documentation is maintained in an orderly manner and current The Registered Manager should explore methods of communication appropriate to the resident group. The Registered Manager should ensure that all training received by staff is recorded. Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Sidcup Local Office 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. Extracts may not be used or reproduced without the express permission of CSCI Thicket Road DS0000006968.V275219.R01.S.doc Version 5.1 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. 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