Inspection on 08/09/05 for Thornton Lodge (105)

This inspection was carried out on 8th September 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

Thornton Lodge (105) 11/07/06

Thornton Lodge (105) 27/01/06

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 Brigstock Road Thornton Heath Croydon CR7 7JL Lead Inspector Peter Stanley Unannounced Inspection 8 September 2005 9:30am 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 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 G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Thornton Lodge Address 105 Brigstock Road, Thornton Heath, Croydon, Surrey, CR7 7JL 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 8684 1056 020 8689 5885 thorntonlodge@btinternet.com Mr Chatrapal Juwaheer Mrs Pauline Juwaheer Mr Ravindranath Dosieah Care Home 33 Category(ies) of Mental Disorder - over 65 (33) registration, with number of places Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: For people with a mental disorder who are over 65 and in agreed circumstances those who are over 55. Date of last inspection 31 January 2005 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 home’s 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 G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 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 provider/owner Mr Chatrapal Juwaheer was present during the course of the inspection, the registered manager not being available. The inspector toured the premises and spoke to a number of service users and staff. Care records and other documentation were 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 very positive. Service users spoken to at the home commented favourably about the care and support they receive at the home and the caring attitude of the staff team. 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 were observed to be interacting with the service users in a caring, respectful and professional manner. The home has addressed a number of requirements from the previous inspection. As a result of this inspection there are a small number of issues which will need to be addressed; these are detailed below. Most concerning was the failure of the home to have completed all staff recruitment checks; this must be addressed as a priority. There are four requirements and four recommendations from this inspection. 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. 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’ health care needs are being fully met. Appropriate policy and procedures are in place for medication. Service users are evidenced as being protected by these procedures. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 6 Service users are encouraged to maintain contact with their family and friends and to retain links with the local community. Service users are assisted to exercise a fair degree of choice and control over their day-to-day routines and decision-making. The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are encouraged to raise any concerns they may have. The home’s policies, procedures and practice evidence that service users are being protected from abuse. Service users live in a safe, well-maintained environment, with access to safe and comfortable communal facilities. Service users’ rooms are safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. The health, safety and welfare of service users and staff are being appropriately promoted and protected. What has improved since the last inspection? Accredited medication training has been extended to all care staff who administer medication. In accordance with the regulations, up-to-date CRB (Criminal Records Bureau) checks are now being made for all new staff appointments. 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 has now met the target of 50 of staff with NVQ Level 2 by 2005. Staff are now being appropriately and regularly supervised; there is, however, a need for one/two senior care staff to assist in meeting this commitment and undertake relevant supervision training. A fire risk assessment and emergency plan have been put in place. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 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 G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 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 standard(s) 3, 4, and 6 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 generally in place, one service user with changing needs requires an updated risk assessment. EVIDENCE: Standards 3 and 4 are met. All standards were met at the last inspection. The service provides care for service users who have long-term chronic mental health histories. It does not accept emergency admissions or provide an intermediate care service (standard 6). New service users are only admitted on the basis of a full assessment undertaken by a person who is suitably qualified to do so. The assessment is done with the service user, relative or delegated representative and relevant professionals that have been party to the referral. The inspector sampled a number the files of three service users who have been admitted since the last inspection. The practice of the home is for the manager Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 10 of the home to complete an assessment of the prospective service user prior to admission. The inspector found assessments to have been fully completed and in place. There was evidence of care management assessments and care plans having been obtained. The registered person was able to demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of the individuals admitted to the home. Service users spoken to by the inspector indicated that their care and support needs were being well met, no concerns being expressed. The inspector was, however, made aware by the registered provider of the problems presented by one recently admitted service user due to his alcohol abuse. The inspector understands that this is being monitored and advice sought. The inspector examined the service user’s file, which was generally well documented. An updated risk assessment must, however, be completed to provide a detailed breakdown of the risks identified and the actions/strategies required to manage these. A requirement applies. The individual needs of service users are identified and met with care plans being monitored and reviewed on a monthly basis. Generally, staff were observed by the inspector to interact well with service users, displaying relevant support and communication skills. The inspector did, however, identify a need for specific training (see standard 30) which would assist in meeting the needs of service users who present challenging behaviour. The home’s service users receive visits from the GP and other medical professionals as and when required. Evidence of good communication with the home’s pharmacist and other professionals was apparent from case notes and other documentation. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 11 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 standard(s) 7, 8 and 9 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’ health care needs are being fully met. Appropriate policy and procedures are in place for medication. Service users are evidenced as being protected by these procedures. Accredited medication training has been extended to all care staff who administer medication. EVIDENCE: Standard 8 is met. Standards 7 and 9 both have one requirement and are unmet. Following the initial assessment, and prior to admission, care plans are drawn up. prior to admission, on admission and during residency. Care plans are reviewed on a monthly basis and involve the service user and/or relatives. The plans set out the individual needs of the residents and how the home aims to meet them. Service users are fully involved in the drawing up of their care Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 12 plans and sign these. There is also a statutory annual review for each service user. A sample of care plans were inspected. These were generally satisfactory, including comprehensive information regarding service users’ mental health, care and support needs, and the actions required to address these. Risk assessments include some covering issues as well as manual handling. Such assessments are carried out by senior staff and reviewed on a regular basis. Each file contains details of all visits to/from the district nurse, GP, hospital and other appointments. There were also arrangements in place for service users to be asked whether they wished to see their care plan. Service users spoken to by the inspector indicated that their health care needs are being well met. The home is registered with a local health centre with GPs visiting as and when required. Both male and female GPs are available to service users, most of whom are registered with the practice. The home enjoys a good relationship with the health centre. Service users are, however, able to remain registered with their previous GP if they so wish. Local district nursing services are provided as appropriate (for leg ulcer care, and vitamin injections), as are visits from the local Community Psychiatric Team. Three service users currently receive regular visits from CPNs (Community Psychiatric Nurses). Community dentists and opticians attend on a 3-6 monthly basis, and an NHS Chiropodist visits every three months. The inspector sampled medication records of three service users. These were found to be satisfactorily maintained. All records of medication received and administered were found to be accurate. The home receives advice and consultation from a pharmacist who visits on a three-monthly basis. The inspector viewed the report of the last visit on 11 August 2005. No concerns were identified. A medication training programme is in place within the home, this being ratified by Superdrug Pharmacy. There is a list of thirteen care staff who administer medication for whom the inspector was advised accredited training has been completed. The inspector subsequently found that one senior carer had not completed this training. A requirement applies. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 13 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 standard(s) 12, 13 and 14 While, generally, service users are being provided with a varied range of socially and culturally appropriate recreational and social activities, the opportunities for their participation need to be extended. Service users are encouraged to maintain contact with their family and friends and to retain links with the local community. Service users are assisted to exercise a fair degree of choice and control over their day-to-day routines and decision-making. EVIDENCE: All four standards were met at the last inspection. 12, 13 and 14 were met on this visit though there is one recommendation relating to standard 12. The home offers a wide range of activities that all service users are given the option of participating in. The activity programme includes music, games, exercise and library visits. During this inspection, some of the service user’s were watching television and another room was used as a quiet space. The inspector observed an activity session in which a number of service users service users participated in a drawing and colouring session. The inspector Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 14 addressed concerns recently expressed by an anonymous complainant that service users were under-stimulated and left to their own devices between getting up and taking lunch. The inspector examined an activities programme which indicated that one hour of structured activity is offered between 11 and 12 noon each day. The registered provider advised that several service users often lacked the motivation to participate in activities that are offered. Service users spoken to by the inspector indicated that they had considerable freedom to go out or to participate in activities if they wished. Staff members regularly accompany service users to shops and out for coffee. Some service users did, however, present as under-stimulated, and indicated that there was little to do, other than watching television, outside of the morning activity hour. The inspector felt that more could be done to increase service users’ motivation by providing staff with more time to engage in discussion with service users and provide opportunities for participating in structured activities outside of the activity hour. To assist this staff need to be released from other (domestic) duties to spend more time with service users. An alternative option discussed with the provider would be for volunteers to be recruited for this purpose. A daily activities log should be maintained. A recommendation applies. The Manager informed the inspector that some service users are able to go out with family and friends, and receive visitors. The home has an open door policy in relation to visitors, as long as the service user agrees to the visits. The home has a visitor’s room and pleasant garden where residents can receive visitors. The home has regular monthly resident’s meetings, which cover issues in relation to the running of the home. The home organises occasional outings, a day trip to Brighton being scheduled in September. Service users are encouraged to express their individuality by maintaining their previous activities and interests, and by furnishing and using their rooms as their very own. Service users’ rooms reflected individual identities with residents bringing their own furniture, furnishings, photographs and possessions. Most service users have their finances managed by social services or relatives. The proprietor acts as agent/appointee to two service users. Records of service users’ personal allowances are maintained, these being found to be in good order. Information concerning service user’s access to advocacy services is available if required. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 15 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 standard(s) 16 and 18 The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are encouraged to raise any concerns they may have. The home’s policies, procedures and practice evidence that service users are being protected from abuse. EVIDENCE: Both the above standards are met. Standard 17 was met at the last inspection. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 16 The home has a clear and satisfactory complaints policy and procedure. The complaints procedure sets out the process for managing complaints and ensures they are dealt with promptly and effectively. The inspector noted the procedure states that any complaint will be responded to within twenty-eight days. Likewise the procedure states that any complaint can be referred to the CSCI, local office at any time during the course of investigation. The complaints book at the home was inspected, no complaints having been recorded since the last inspection. Any complaint recorded details the outcome of the investigation and what action (if any) was taken. 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. The provider informed the inspector that all staff have attended the Croydon one day course in adult protection. Also, that the registered manager has acted on the advice given by the inspector at the last inspection and attended an accredited ‘Training for Trainers’ training course on adult protection. This will enable adult protection training to be cascaded within the home to all staff. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 17 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 standard(s) 19, 20, 23, 24 and 26 Service users live in a safe, well-maintained environment, with access to safe and comfortable communal facilities. Service users’ rooms are safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Generally, the home presents as clean, pleasant and hygienic. However, action needs to be taken to ensure that hygiene is appropriately maintained in one service user’s room. EVIDENCE: All eight standards were met at the last inspection. Five standards were inspected on this visit and met. The home was inspected and found to provide a pleasant, safe and wellmaintained environment for the home’s service users. The home has been assessed by an occupational therapist and all recommendations have been Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 18 implemented. The home presents as comfortable, homely and pleasant, with three separate lounges being provided (one for smokers), a main dining area and a small, quieter one (on the first floor), and a pleasant conservatory overlooking the garden. Service users are encouraged to access the very pleasant garden though in spite of being a pleasant, warm, sunny day, few were observed to do so. There are 31 single rooms and 1 double bedroom for the 33 service users. The home’s owner advised that the double bedroom is to be converted into two single bedrooms as part of a planned expansion of the home. All bedrooms have a lockable facility. A number of service users’ bedrooms were inspected and found to be comfortably and pleasantly furnished, and in a good decorative state. Service users spoken to by the inspector expressed satisfaction with their rooms and with their living environment within the home. The home was generally found to be clean, hygienic and free from offensive odours. There were, however, unpleasant odours in one service user’s room associated with urine. The provider advised that new carpeting had been laid three months previously but that due to the resident’s urinary problems weekly shampooing was unable to offset the odours. The inspector recommends that the carpeting is either cleaned on a more regular basis or, in consultation with the service user, agreement reached for replacement with a more easily washable linoleum or vinyl floor covering. The home is well provided for with regard to measures to minimise crossinfection. Laundry facilities, including a sluice-cycle and disinfection-cycle washing machine, are sited in the basement. Commode pot and bottle sterilisers are sited on both floors. Hand washing facilities are prominently sited as necessary around the home. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 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 has now met the target of 50 of staff with NVQ Level 2 by 2005. Whilst the home has a recruitment policy and procedures in place, there are shortcomings in the completion of the home’s recruitment checks. This represents a potential risk to the protection of service users. Generally, staff are being provided with the necessary induction and training with which to competently perform their work duties. The protection and welfare of service users and staff necessitates, however, that all staff must attend training specific to the needs of service users who present mental health problems and challenging behaviour. EVIDENCE: The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s service users. The home has 26 care staff and 2 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. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 20 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. Since the last inspection the home has achieved an increase int the numbers of care staff holding NVQ Level 2, from two to thirteen; this represents 50 of the staffing complement and meets the minimum ratio of 50 trained members of staff with NVQ Level 2. One staff member has completed NVQ level 3 while another has an NVQ level 4. 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 completed checks of staff files and found that up-to-date CRB (Criminal Records Bureau) checks had been completed in respect of three new staff members. The inspector noted, however, that other staff recruitment checks were incomplete. Two of the three files evidenced only one reference, one of which was very brief and said very little about the applicant’s capabilities. No proof of identity was available for one applicant while two files did not include a photo of the applicant or a copy of the applicant’s birth certificate. The inspector is very concerned about these shortcomings and is making it a requirement that all recruitment checks are, in future, completed prior to any new staff member commencing employment at the home. The inspector recommends that each staff file includes a checklist at the front of the file, detailing the recruitment and identity checks required and the date when these have been completed. The home has developed a Training and Development Programme. All staff appointed to the home receive a TOPPS induction programme, with evidence gathered while completing this being used to support NVQ level 2. The home has bought in a package that will cover training on Moving and Handling, First Aid, Health and Safety, Fire Safety and Basic Food Hygiene. The inspector was advised that 10 staff have recently completed training in Moving and Handling, with 13 staff having completed First Aid training. A further 7 staff (16 in total) have completed training in Infection Control at Bromley College. The inspector identified a need for training in two key areas: Working with service users who present mental health problems; and Working with service users who present challenging behaviour. Requirements apply. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 and 38 Staff are now being appropriately and regularly supervised; there is, however, a need for one/two senior care staff to assist in meeting this commitment and undertake relevant supervision training. The health, safety and welfare of service users and staff are being appropriately promoted and protected. EVIDENCE: Standards 33, 34, 35 and 37 were met at the last inspection. Supervision has now been developed at the home to a broader process between the supervisor and supervisees and now covers all the elements of standard 36.3. The inspector examined supervision records, which reflected this broadening of approach. A requirement from the last inspection has been met with staff receiving supervision on at least a bi-monthly basis. This improvement in the Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 22 frequency of supervision must be sustained and will be checked out again at the next inspection. Standard 36.2 states that supervision must occur “at least six times a year”. The inspector understands that the Registered Manager currently undertakes all supervision. The inspector discussed this with the Registered Provider and recommends that two senior carers are provided with the opportunity to do the LB Croydon’s Supervision training with view to sharing the supervision workload. The inspector completed health and safety checks, which were found to be upto-date and satisfactory. All services, equipment and facilities are maintained in a safe state to ensure the health and safety of the service user and staff. The home has a valid five yearly electrical certificate and PAT testing has been carried out. The manager ensures that there are safe working practices including moving and handling techniques for the safety of the service users and staff is in place. Risk Assessments for safe working practices are in place. Food and hygiene procedures are in place to ensure the safety of staff and service users, and sixteen staff have now undertaken ‘approved’ infection control training. All Accidents and Incidents are recorded in an appropriate manner. Safety procedures are in place. All staff have induction in health and safety and foundation training updates are facilitated. Following a requirement from the last inspection a Fire Risk Assessment and emergency plan have been put in place. Protection with regard to Fire safety training is carried out every twelve months by an ‘approved company’ to ensure that all staff are clear of what actions to take should such an event occur, the last recorded training session was on 5 April 2005. A fire drill was last held on 22 August 2005. Fire awareness and training is seen as paramount at this home although the inspector suggests that fire training is carried out at least every six months in line with recommendations from the local fire service. Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x 3 x 3 Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 24 No 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 OP4 Regulation 13(4)b&c Requirement An updated risk assessment must be put in place for a recently admitted service user who presents risks associated with alcohol abuse. This must provide a detailed breakdown of the risks identified since admission and the actions/strategies required to manage these. A copy must be forwarded to the CSCI, Croydon Office. The Registered Manager must ensure that all care staff who administer medication have completed accredited medication training. The Registered Manager must ensure that all staff recruitment and identity checks are completed prior to the confirmation of any staff appointment. 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. Timescale for action 1 October 2005 2. OP9 13(2) 1 January 2005 3. OP29 19(1)a,b & c, Schedule 2 18(1)a & c 1 October 2005 4. OP30 1 April 2006 Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 25 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 OP 12 Good Practice Recommendations The inspector recommends that staff are allocated more time to engage service users in structured activities (or volunteers recruited for this purpose). This should be evidenced in a daily activities log. The inspector recommends that the carpeting of Room 14 is either cleaned on a more regular basis or, in consultation with the service user, agreement reached for replacement with a more easily washable linoleum or vinyl floor covering. The inspector recommends that each staff file includes a checklist at the front of the file, detailing the recruitment and identity checks required and the date when these have been completed. The inspector recommends that two senior carers are provided with the opportunity to do the LB Croydon’s Supervision training with view to sharing the supervision workload. 2. OP26 3. OP29 4. OP36 Thornton Lodge G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 26 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon Surrey 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 G53 S25860 ThorntonLodge V226426 080905 stage4.doc Version 1.40 Page 27 - 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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