Inspection on 14/02/06 for Thorpedale

This inspection was carried out on 14th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thorpedale 28/06/07

Thorpedale 07/06/06

Thorpedale 09/08/05

Thorpedale 26/01/05

Thorpedale 03/08/04

Thorpedale 22/01/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Thorpedale 1 Station Approach Chorleywood Rickmansworth Hertfordshire WD3 5AJ Lead Inspector Jeffrey Orange Unannounced Inspection 14th February 2006 08:20 Thorpedale DS0000019594.V282966.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 Thorpedale DS0000019594.V282966.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. Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thorpedale Address 1 Station Approach Chorleywood Rickmansworth Hertfordshire WD3 5AJ 01923 284648 01923 284648 thorpedale@tesco.net 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) Watford and District Mencap Keith Philip Seager Care Home 7 Category(ies) of Learning disability over 65 years of age (7), registration, with number Physical disability over 65 years of age (7) of places Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Thorpedale is a large, two storey, detached house that offers seven single occupancy bedrooms. One double bedroom has recently been divided to create two single bedrooms. The rooms are currently unoccupied as they require carpet and curtains. Two of the single occupancy bedrooms are located on the ground floor. There is a kitchen, a lounge/dining room and a laundry that are also situated on the ground floor. The home is surrounded by gardens that contain a variety of features such as a patio area, a vegetable patch and raised flowerbeds. There are a variety of shops within a short walking distance and an underground station providing links with central London. Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours in the morning. It was focussed principally on monitoring progress with those requirements and recommendations that were made following the previous inspection in August 2005. In the absence of the registered manager, the inspection was facilitated by the acting deputy manager, who provided very professional and efficient assistance. It was possible to see and speak to most of the five residents currently living in Thorpedale, together with the home’s activity co-ordinator. Medication and care plans were inspected and a brief tour of the house and grounds was undertaken to monitor the environment of the home. The standard of care seen was good and the interaction between members of staff and residents was relaxed and appropriate. Although some progress has been made in addressing the issues raised at the previous inspection, there remain areas of concern that have not yet been fully addressed, particularly in relation to the administration of medication and associated records and also in respect of the home’s environment. The majority of the key standards were assessed during the previous inspection of the 9th August 2005. Where that is the case they have not always been re-assessed on this occasion and therefore, for full details, reference should be made to the report of that inspection. What the service does well: The standard of care provided for residents is good and the care plan records indicate that residents are supported by a range of professional health and social care services. There are several examples of the service encouraging residents to retain their independence in a very real sense, for example by unaccompanied access to community services and self-medication. Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Thorpedale DS0000019594.V282966.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 Thorpedale DS0000019594.V282966.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): These key standards were assessed during the inspection of the 9th August 2005, for full details please see the report of that inspection. EVIDENCE: Thorpedale DS0000019594.V282966.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 Although the care-plan documentation is quite comprehensive, it would benefit from a process of review and reflection on the format, to ensure that the changing needs of residents and how they are being met are fully and accurately recorded and maintained up to date. EVIDENCE: Medication information for residents is included in several parts of the care plan documentation, including the medication folder, and in one case at least was not completed consistently with the full, current position. Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13 Residents have access to a range of community leisure and social activities and some are able to access these unaccompanied within a risk assessment framework. A range of specialist health and social care services are available to and are accessed by residents to provide counselling and therapy. EVIDENCE: Some residents were seen to be collected for day care and others were being prepared to go out for part of the morning in the course of this inspection. Care plans include details of a range of community services involved in the healthcare or social and spiritual lives of residents. Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 11 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 21 It is positive that at least one resident is encouraged and helped to selfmedicate. The overall standard of medication practice in the home remains inconsistent. The home has recent experience of dealing with the death of a resident and has also enabled the wishes of some residents in the event of their deaths to be sensitively discussed. EVIDENCE: One resident monitors some key health readings, which are then recorded by staff, this promotes his independence. Medication records contained some gaps and inconsistencies, this does not provide for confidence in the consistent and safe provision of medication to residents. A very good example of discussing and recording the wishes of residents around the issues of their death was seen to be in place within care plan documentation. Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 12 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): These key standards were assessed during the inspection of the 9th August 2005, for full details please see the report of that inspection. EVIDENCE: Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 13 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 30 Although efforts have been made to address some of the issues previously raised, the overall standard of maintenance and décor in the home remains a matter of concern. EVIDENCE: There is still a noticeable odour of urine in one bedroom. Plug in air fresheners are in place although not always operative. There are various areas of the home that show signs of wear and tear and require routine maintenance. Some areas of floor covering are missing, for example in one upstairs toilet. No bin was available for used paper towels in the same toilet and the door was very stiff to open. The garden remains rather unkempt even allowing for the season of the year, and garden furniture has not been stored away and will now require cleaning to remove mould and dirt. Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 14 It is understood that the exterior of the building has recently been assessed, although to-date the condition remains as it was at the time of the last inspection. Thorpedale DS0000019594.V282966.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): These key standards were assessed during the inspection of the 9th August 2005, for full details please see the report of that inspection. EVIDENCE: Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 16 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): These key standards were assessed during the inspection of the 9th August 2005, for full details please see the report of that inspection. (Specific requirements made during that inspection have been met) EVIDENCE: Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 17 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 3 X X X X X X X Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 18 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 YA6 Regulation 15(2) Requirement Timescale for action 31/07/06 2 YA20 13(2) Care plans should be reviewed in the light of service users’ changing care needs and kept up to date. 14/02/06 Medication records must be accurately kept. Medication containers must be dated on opening. Amounts of medication must be carried forward and recorded to enable reconciliation to take place. These requirements have been brought forward from the previous report and must now be addressed as a matter of urgency. 3 YA24 23 The internal environment of the home must be well maintained. The garden must be well maintained The external window DS0000019594.V282966.R01.S.doc 31/07/06 Thorpedale Version 5.1 Page 19 frames must be repaired. These requirements have been brought forward from the previous report and must now be met as a matter of urgency. 4 YA30 16(k) The odour of urine in the bedroom identified during this inspection must be satisfactorily addressed. 30/07/06 Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 20 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 Refer to Standard YA6 YA20 Good Practice Recommendations A systematic process of reflection on and review of the home’s care plan format and records should be considered. Where service users are involved in self-medication or selfmonitoring of health signs, a protocol based on a risk assessment process should be drawn up. This promotion and enabling of self-medication is to be encouraged. Staff training in medication practice and procedures should be reviewed and use made of training such as that discussed at the inspection under the auspices of Hertfordshire LD Workforce training. A structured programme of routine maintenance and decoration should be drawn up, with dates for completion and funding identified, to ensure that the premises are well maintained. 3 YA20 4 YA24 Thorpedale DS0000019594.V282966.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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