Inspection on 27/01/06 for Thornton Lodge (105)

This inspection was carried out on 27th 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 but made no statutory requirements on the home.

Other inspections for this house

Thornton Lodge (105) 11/07/06

Thornton Lodge (105) 08/09/05

Thornton Lodge (105) 31/01/05

Thornton Lodge (105) 10/05/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOMES FOR OLDER PEOPLE Thornton Lodge (105) 105 Brigstock Road Thornton Heath Croydon Surrey CR7 7JL Lead Inspector Peter Stanley Unannounced Inspection 27th January 2006 9:30am 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 Thornton Lodge (105) DS0000025860.V278927.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 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. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thornton Lodge (105) Address 105 Brigstock Road Thornton Heath Croydon Surrey CR7 7JL 020 8684 1056 020 8689 5885 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) Mr Chatrapal Juwaheer Mrs Pauline Rosina Juwaheer Mr Ravindranath Dosieah Care Home 33 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (0) of places Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. For people with a mental disorder who are over 65 and in agreed circumstances those who are over 55 8th September 2005 Date of last inspection Brief Description of the Service: Thornton Lodge is formed of three co-joined, substantial Victorian houses, set amidst the local community of Thornton Heath. Being on the main road through this district - with shops, pub and the local library across the road and public transport connections either outside the door (busses), or just down the road (Railway station and major bus terminus), the homes location could hardly be bettered. As a contrast to this hustle and bustle, the back gardens to the home - separate and yet interconnected - provide an oasis of calm for service users who want to find their way to the quiet and peace of a protected environment. The service provided at the home ensures care with bed and full board for up to 33 people with past or present mental ill health. The registration of the home allows principally for those over pension age - but also includes persons of the age of 55 upwards. This extra category allowance allows for those adults who prefer a more mature focus to their living environment rather than sharing with comparative youngsters. The communal rooms are pleasant - plenty of lounges provide both smoking and non-smoking space. There is also a spacious dining area along the back of the house. 31 single bedrooms and one double-occupancy bedroom provide a high level of privacy for users. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the home took place over one day. The registered manager, Mr Ravindranath Dosieah, assisted throughout the course of the inspection, with some assistance being provided by the registered provider and owner, Mr Chatrapal Juwaheer. The inspector spoke to a large number of service users, and to staff on duty. Care assessments, care plans, risk assessments, staff files, accident/incident and complaints records, and other documentation were all examined. The inspector’s overall impression is that this is a well run home, which provides a caring and homely environment for the home’s residents. Feedback from service users and staff was generally favourable, with many positive comments being made regarding the home and the support provided. Overall the inspector found Thornton Lodge to be a comfortable, relaxed and well managed home. The staff on duty at the time of the inspection presented as supportive and enabling, and were observed to be interacting with service users in a caring, respectful and professional manner. The home has addressed all but one requirement from the previous inspection. As a result of this inspection there are 8 requirements and 6 recommendations that will need to be addressed; these are detailed below. What the service does well: The home is able to demonstrate that service users’ needs are being properly assessed, and that the range of needs presented is being appropriately met. Prospective service users, their relatives and friends are provided with the opportunity to visit and assess the quality, facilities and suitability of the home. Service users are having their health, personal and social care needs set out in an individual plan of care, the service user and his relative(s)/representative(s) being involved in this process. Service users are being treated with respect and their privacy is being maintained. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The home needs, however, to ensure that it continues to meet the target of 50 of staff with NVQ Level 2. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 6 The home is being managed in the best interests of the home’s service users. The management approach is evidenced to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. Generally, the health, safety and welfare of service users and staff are being appropriately promoted and protected. Road safety training must, however, be arranged for all service users who live in the home. What has improved since the last inspection? Service users are being protected by the home’s medication policy and procedures. Accredited medication training has now been extended to all those care staff who administer medication. With the development of more opportunities, service users are being provided with a range of socially and culturally appropriate recreational and social activities. There is, however, a need for further development of structured activities within the home if service users’ needs are to be more fully met. The home has been developing its quality assurance processes, and is evidencing extensive consultation with service users, relatives and other parties. However, a development plan, outlining the audit outcomes, and plans to address these, needs to be put in place. While staff are now being regularly and appropriately supervised, there is a need for one/two senior care staff to assist with supervision and undertake relevant supervision training. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 7 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. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 8 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 Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is able to demonstrate that service users needs are being properly assessed, and that the range of needs presented is being appropriately met. While risk assessments are being completed, a more detailed and structured risk assessment format is required, so as to provide clearer guidance to staff regarding the nature of each risk and the actions required to safeguard the service user. Prospective service users, their relatives and friends are provided with the opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: Standards 3, 4 and 5 assessed. The inspector looked at the file of a service user who has been recently admitted to the home. The practice of the home is for the manager of the home to complete an assessment of the prospective service user prior to admission. The inspector found assessments and risk assessments to have Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 10 been completed and in place. The inspector spoke with the service user who indicated that he had settled well since his move from a hostel and that his care and support needs were being well met. The inspector spoke to a wide range of service users during the inspection. The feedback received was generally very positive, with service users indicating that they were receiving a good standard of care from staff, and to be feeling well supported in their day-to-day living and social activity. No concerns were expressed though one service user was non-committal when asked for his views about the home. The inspector’s observed staff interacting with service users in a caring and enabling way, displaying relevant support and communication skills, and being professional in their approach. Following a concern identified from the previous inspection, a new risk assessment has been completed for a service user who had presented problems associated with alcohol abuse. The registered manager advised that the service user has settled in well since his admission in April and that the behavioural problems, which had been previously experienced with his drinking, were no longer occurring. The inspector was made aware of a concern regarding a service user who was hit by a vehicle when crossing the main road outside of the home. This resulted in the service user sustaining shock and injuries, and in affecting his mobility and confidence. Whilst the service user is relatively independent and has been used to going out alone, there is a need for the home to complete a risk assessment with the service user so as to fully assess the risks, and actions required to minimise these, when crossing the busy road; a requirement applies. The inspector spoke with the service user who indicated that he was recovering well from the accident and had been receiving appropriate support and health care. As a result of the accident the inspector is requiring the home to arrange for road safety training to be provided for all service users (as detailed in standard 38). The inspector discussed the arrangements for initially assessing prospective service users and enabling them to visit and assess the home. The manager advised that following a referral, the person being referred is invited to visit and spend a day at the home, to have lunch and meet with staff and service users. There is initial discussion around the person’s needs and expectations, and information provided regarding the home’s routines and activities, community facilities, and any house rules that apply. A second visit, with an overnight stay, can subsequently be arranged if required. If wishing to proceed with an admission, a date for a pre-assessment, involving the prospective service user and his/her nearest relative or friend/representative, is arranged, and a date set for his/her admission. The admission is then subject to a 28 day trial period, following which the service user is able to confirm whether or not he wishes to stay, and a decision taken on whether to admit on a permanent basis. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 11 On the basis of this discussion the inspector was satisfied that there is sufficient opportunity for prospective service users, their relatives and friends to assess the suitability of the home before a final decision is made. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users are having their health, personal and social care needs set out in an individual plan of care, the service user and his relative(s)/representative(s) being involved in this process. Service users are being protected by the home’s medication policy and procedures. Accredited medication training has now been extended to all those care staff who administer medication. Service users are being treated with respect and their privacy is being maintained. EVIDENCE: Standards 7, 9 and 10 assessed. The inspector examined the service user plan of a service user who has been recently admitted to the home. This was completed with the service user and includes comprehensive information regarding the service user’s mental health, care and support needs, and the actions required to address these. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 13 The home’s medication policy and procedures were last reviewed in August 2005 and have been evidenced to provide the necessary level of protection for service users. All medication records examined on the previous and present inspections were found to be accurate and well maintained. Advice from a pharmacist concerning the home’s policies and procedures is given on a three monthly basis, the last visit having taken place on 17/11/05. A medication training programme is in place within the home, this being ratified by the pharmacy. There is a list of thirteen care staff who administer medication for whom accredited training has been completed. One senior carer has also now completed this training. There are no service users who currently administer their own medication. One service user is taking a controlled drug. The inspector checked the storage arrangements and found that this is being securely stored in a locked compartment within a locked medication cupboard in the manager’s office. The inspector spoke to a number of service users regarding their privacy. Views expressed indicated that staff are generally being considerate and cognisant of their right to privacy. Staff were observed by the inspector to be respectful towards service users, and to knock on doors before entering service users’ rooms. The home has appropriate facilities available for receiving visitors. This includes a small meeting room for service users who may wish to meet privately with professionals, friends or relatives. A small dining area on the first floor, and the conservatory off the dining area, are other suitable areas for this purpose. A public telephone is available in a hooded acoustic location. Service users are able to use their rooms at any time of the day or night. There is one double-occupancy room in the home. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): With the development of more opportunities, service users are being provided with a range of socially and culturally appropriate recreational and social activities. There is, however, a need for further development of structured activities within the home if service users’ needs are to be more fully met. EVIDENCE: Standard 12 assessed. Service users spoken to by the inspector indicate that they are able to participate in a range of activities, if they wish, within the home, and to go out and access facilities in the community. Staff members regularly accompany service users to shops and out for coffee. There is a daily activities hour between 11 and 12 pm. This can include quizzes, bingo, board games, art and drawing, reminiscence and music sessions. Following a recommendation from the last inspection, the home has been making efforts to extend the range of activities on offer and to develop the abilities of staff in facilitating activities. The inspector spoke with one senior care worker who is developing reminiscence work with service users. Activities tend, however, to be confined to the daily activity hour, with only occasional activities being arranged at other times. The manager advised that staff are now facilitating music sessions, and group discussions, and that there are plans to use a volunteer to Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 15 provide occasional musical entertainment. While the home is making some progress in this area, there is a need for further development of structured activities at times other than the daily activity hour, and for encouraging staff to develop relevant skills. The inspector evidenced that service users’ activities are being logged on a daily basis, as recommended in the previous inspection report. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While service users are generally being protected from abuse by the home’s policies and procedures, their protection also requires that those staff who have not yet done so, complete statutory adult protection training. EVIDENCE: Standard 18 assessed. No complaints received since the last inspection. The inspector was advised that there have not been any adult protection concerns since the previous inspection. Service users presented as settled and well cared for. No concerns were expressed. The home has an Adult Protection and Whistle Blowing Policy in place for staff to reference should the need arise. These provide clear guidelines regarding the nature of abuse and the actions to be taken when an incident of abuse occurs or is suspected. The registered manager advised that 4 staff will need to attend Croydon’s multi-agency one day course in adult protection, all other staff having completed this training; a requirement applies. The registered manager also advised that, contrary to the impression given at the last inspection, he has not attended an accredited ‘Training for Trainers’ training course on adult protection. Given his current commitments, it was proposed that this training be made available for one of the home’s senior care workers. This would enable Croydon’s adult protection training to be cascaded within the home to all staff. A recommendation applies. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 17 Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed. Standards 19, 20, 23, 24 and 26 met at the last inspection. Concerns identified from the last inspection, regarding hygiene in a service user’s room, no longer apply. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The home needs, however, to ensure that it continues to meet the target of 50 of staff with NVQ Level 2. While, generally, the home’s service users are being protected by appropriate recruitment policy and procedures, the home has failed to obtain a criminal records check for a new staff member. This is placing service users at potential risk. EVIDENCE: Standards 27, 28 and 29 assessed. The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s service users. The home currently has 24 care staff and 3 ancillary staff. The inspector viewed staff rotas. These confirmed that were sufficient staff on duty, with 5 on duty throughout the day and 2 waking and 1 sleep-in overnight. Staffing levels are in accordance with the original agreement prior to the Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older people. This is subject to adjustment should the dependency of the service users increase or if a crisis occurs that would warrant an increase in staffing levels. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 20 The home has previously achieved an increase in the numbers of care staff holding NVQ Level 2, from two to thirteen; this has, however, decreased to 11 carers, two having left since the last inspection. This represents just under 50 of the staffing complement, thus falling just short of the 50 target of trained members of staff with NVQ Level 2. The inspector understands that one senior care worker has completed NVQ level 3. The inspector was advised that a senior care worker and the registered provider are undertaking the A1 A2 assessor’s course as had been previously recommended. The inspector identified a need for one of the two senior care workers to have the opportunity to progress to NVQ Level 3; a recommendation applies. The inspector examined the files of two recently recruited staff members and found that an up-to-date CRB (Criminal Records Bureau) check has not yet been obtained in one case. The inspector was provided with verification of a POVA First check. However, the manager was advised that various criteria (designed to protect service users) must be fulfilled, and a request put in writing, before any decision could be made regarding the employment of any new staff member without a CRB certificate. For any future occasion where the home wishes to start a new staff member, without having first received a CRB certificate, the home must write to the CSCI inspector to request agreement for a new staff member to commence work at the home. A copy of the POVA First check must be enclosed, and evidence provided that all other documentation detailed in Schedule 2 of the Care Home Regulations has been obtained. An assurance must be given that, until the CRB certificate has been received: 1. That the new staff member will have no one to one contact with any service user (including taking out any service user from the home. 2. That the new staff member will not assist any service user with their personal care. 3. That the home ensures that the new staff member is supervised on all shifts by an experienced staff member. Named staff member(s) who will be supervising, must be identified. Permission for the person to commence employment at the home must be received in writing from the inspector. This procedure must be followed for any future occasion where there is likely to be a long period of delay in processing the CRB, and where there is an Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 21 urgent need for the home to commence the person’s employment. This can be defined as those circumstances in which service users’ health and welfare would be placed at critical risk, and does not apply to planned or routine recruitment of staff. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is being managed in the best interests of the home’s service users. The management approach is evidenced to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. The home has been developing its quality assurance processes, and is evidencing extensive consultation with service users, relatives and other parties. However, a development plan, outlining the audit outcomes, and plans to address these, needs to be put in place. While staff are now being regularly and appropriately supervised, there is a need for one/two senior care staff to assist with supervision and undertake relevant supervision training. Generally, the health, safety and welfare of service users and staff are being appropriately promoted and protected. Road safety training must, however, be arranged for all service users who live in the home. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 23 EVIDENCE: Standards 31, 32, 33 and 36 assessed. The registered manager, Mr Ravindranath Dosieah, presents as suitably qualified and experienced to run the home. He has a great deal of management and supervisory experience working with vulnerable people in different settings, and has recently completed studies leading to the award of NVQ Level 4 and the Registered Managers Award. The inspector found that the home is generally being well run, with the manager being well regarded by both service users and staff. From the inspector’s observations, and the feedback provided, the management style is one that encourages openness and inclusivity, being both supportive and enabling in its approach. Service users are, wherever possible, encouraged to participate in the day-today operation of the home and to express their views through service user meetings, care plan reviews and informal discussions with their key worker or other staff. Staff have the opportunity to express their views in monthly staff meetings, and are consulted within supervision. Throughout the course of the inspection staff were observed to interact well with service users and to work together effectively as a team. The views of relatives are obtained by means of phone contact, invitations to reviews, and visits to the home, where relatives are able to meet and talk directly with care staff and the manager. Service users’ meetings are held on a regular monthly basis, the minutes of recent meetings being evidenced. The home has developed Service User and Staff Satisfaction surveys, together with a Stakeholders Rating Survey. The home has circulated questionnaires to service users, relatives and others, to obtain their views on a wide range of issues relating to the quality of care, support and services provided in the home. An annual quality assurance review was completed in November 2005. The home has yet to compile an annual development plan; a requirement applies. There is a supervision process which now covers all the elements of standard 36.3. The frequency of supervision has increased, in line with Standard 36.2, and is now occurring on at least a bi-monthly basis. This improvement in the frequency of supervision must be sustained and will be checked out again at the next inspection. The inspector understands that the Registered Manager currently undertakes all supervision. The inspector previously addressed this issue with the Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 24 Registered Provider and has recommended that two senior care workers attend LB Croydon’s Supervision training with view to their sharing the supervision workload. This would assist in lightening the manager’s currently extensive supervisory responsibilities, and provide the opportunity for the two senior care workers to gain experience of supervision and assist their continuing professional development. Recommendations apply. The inspector identified a need for a more detailed supervision format to be developed, so as to provide a more structured and detailed record of supervision than is currently the case; a requirement applies. This should include an agenda of issues identified for discussion (including issues bought forward from the previous supervision), and then (in separate columns) details of each issue discussed, the discussion points covered, and the actions/decisions agreed. Supervision should cover all aspects of practice, the philosophy of care in the home and career/professional development needs. Supervision notes should be signed and dated by both the supervisor and supervisee. Up to date and satisfactory health and safety checks were made at the last inspection. The inspector identified a health and safety issue relating to road safety awareness. This was prompted by a recent incident in which a service user was hit by a vehicle when crossing the main road outside the home. A requirement is being made for the service user to be risk assessed, and a further requirement for Road Safety training to be arranged for all service users in the home. Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X x STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 2 X 2 Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 26 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 OP4OP7 Regulation 13(4)(b) & (c) Requirement A risk assessment must be completed, regarding the risks involved in crossing the main road, for a service user who was recently injured after being hit by a vehicle. Actions required to address and prevent the risk must be specified. A new risk assessment format must be developed and put in place. This must specify the type or nature of risk being assessed, the level of risk involved (whether high, medium or low), the actions required to minimise the risk, and by whom (including the actions required of the service user). The risk assessment must fully involve the service user and be signed and dated by both the service user, and the person completing the assessment. A date must be included for review. The registered manager must ensure that those staff who have not yet undertaken Croydon’s multi-agency one day course in DS0000025860.V278927.R01.S.doc Timescale for action 28/02/06 2 OP7 13(4)(b) & (c) 31/03/06 3 OP18 12(1), 13(6) 30/04/06 Thornton Lodge (105) Version 5.1 Page 27 4 OP29 19(1)(b) (ii) Sh2No7 adult protection, do so as a priority. The registered person must obtain a CRB check for a recently recruited staff member, and forward a copy of this to the CSCI, Croydon office. For any future occasion where the home wishes to start a new staff member, without having first received a CRB certificate, the home must write to the CSCI inspector to request agreement for a new staff member to commence work at the home. A copy of the POVA First check must be enclosed, and evidence provided that all other documentation detailed in Schedule 2 of the Care Home Regulations has been obtained. An assurance must be given that, until the CRB certificate has been received: 1. That the new staff member will have no one to one contact with any service user (including taking out any service user from the home. 2. That the new staff member will not assist any service user with their personal care. 3. That the home ensures that the new staff member is supervised on all shifts by an experienced staff member. Named staff member(s) who will be supervising, must be identified. Permission for the person to commence employment at 31/01/06 Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 28 the home must be received in writing from the inspector. This procedure must be followed for any future occasion where there is likely to be a long period of delay in processing the CRB, and where there is an urgent need for the home to commence the person’s employment. This can be defined as those circumstances in which service users’ health and welfare would be placed at critical risk, and does not apply to planned or routine recruitment of staff. 5 OP30 18(1)a & c Training must be provided in two key areas: Working with service users who present mental health problems; and Working with service users who present challenging behaviour. A more detailed supervision format should be developed so as to provide a more structured and detailed record of supervision. Supervision should cover all aspects of practice, the philosophy of care in the home and the staff member’s career/professional development needs (36.3). The supervision format should include an agenda of issues identified for discussion (including issues b/f from the previous supervision), and then (in separate columns) details of each issue discussed, the discussion points covered, and the actions/decisions agreed. Supervision notes should be signed and dated by both the supervisor and supervisee. The registered manager must DS0000025860.V278927.R01.S.doc 30/04/06 6 OP36 18(2) 31/03/06 7 OP38 12(1a) 30/04/06 Page 29 Thornton Lodge (105) Version 5.1 13(4b,c) 8 OP33 24(1)(2)( 3) ensure that ‘road safety training’ is made available to all service users who live at the home. Written guidelines on road safety must be issued to all service users. A development plan, outlining the quality assurance audit outcomes, and plans to address these, must be put in place. 30/04/06 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 OP7 OP12 OP16 Good Practice Recommendations The inspector recommends that the home develop ‘personcentred’ care plans in line with PCP guidelines. Further development of structured activities for service users needs to take place. The inspector recommends that the home provides the opportunity for a senior care worker to attend Croydon’s ‘Training for Trainers’ course in adult protection. This will enable Croydon’s training in adult protection to be cascaded to all staff within the home. The inspector recommends that the senior care worker, who is currently qualified to NVQ Level 2, has the opportunity to attend training leading to NVQ Level 3. The inspector recommends that there is some delegation of the supervisory workload to two senior care workers. To facilitate this, the job description requires revision so as to include supervisory responsibilities. The inspector recommends that two senior carers are provided with the opportunity to attend Croydons supervision and appraisal training with view to sharing the supervision workload. 4 5 OP28 OP36 6 OP36 Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Thornton Lodge (105) DS0000025860.V278927.R01.S.doc Version 5.1 Page 31 - 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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