Inspection on 13/10/05 for Throwleigh Lodge

This inspection was carried out on 13th October 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Throwleigh Lodge 10/11/08

Throwleigh Lodge 28/11/07

Throwleigh Lodge 20/02/07

Throwleigh Lodge 14/04/05

Throwleigh Lodge 23/09/04

Throwleigh Lodge 13/05/04

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

CARE HOME ADULTS 18-65 Throwleigh Lodge The Ridgeway Horsell Woking Surrey GU21 4QR Lead Inspector Suzanne Magnier Announced Inspection 13th October 2005 09:00 Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 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 Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 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. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Throwleigh Lodge Address The Ridgeway Horsell Woking Surrey GU21 4QR 01483 772901 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) Wingreach Limited Mr Hassam Gora Soliman Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age range of persons accommodated will be 40 - 65 years Accommodation and Services may be provided to eight (8) named residents over the age of 65 years. Accommodation may only be provided to the two (2) named residents with Dementia with prior written agreement of the CSCI. 5th July 2005 Date of last inspection Brief Description of the Service: Throwleigh Lodge is a large detached property set in a quiet residential area close to Woking town Centre. Care is provided to seventeen men and women who have learning difficulties, some of who may require nursing care. Accommodation is arranged over the ground floor and first floor, with each floor consisting of a shared lounge and dining areas, bedrooms, bathrooms and toilets. The home also has an activity and cookery room and sensory room. The main office and kitchen are situated on the ground floor. The home has a garden to the rear, which is accessible to residents and ample off street parking at the front of the building. Wingreach Limited employs the Registered Manager, catering and housekeeping staff. Surrey Borders Partnership NHS Trust oversees the overall care responsibility of the home and employment of care staff. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours. The inspector met with the majority of residents and some resident’s relatives all of whom spoke highly of the care and attention received by the Registered Manager and staff at Throwleigh Lodge. The inspector spent the day with several of the residents and made a tour of the premises and looked at various documents including resident care plans and risk assessments, staff recruitment files, policies and procedures, financial management and staff rotas. The main focus of the inspection was based on the requirements made during the previous inspection on the 14th April 2005. The inspector observed the breakfast and midday meal being served and watched as staff supported residents with their activities and hobbies. Several comment cards from Health care professionals and residents friend and family were received by CSCI and comments have been included within the report. A variation to change the registration age category and category to support two named persons with Dementia was approved by CSCI in 2005. The inspector would like to thank the residents their relatives and all staff for their cooperation and hospitality during the inspection. What the service does well: What has improved since the last inspection? There was noted to be a marked improvement in the assessment process and documentation regarding a person wishing to become a resident at the home. The assessment records care plans and risk assessments were well Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 6 documented to support staff with clear guidance in the support of an individual. It was encouraging to note that the homes staff had made a concerted effort to develop a more holistic approach to the care of the residents and this was evidenced in the less clinical approach to care and a concentration on the leisure and interests of residents to offer quality time and stimulation. The inspector commented on the general improvement of one resident whose behaviour in the past inspections had been noted as unpredictable and unsettled. During the inspection the resident was calm and appeared to know the sequence of events in the home. The inspector concluded the improvement in the resident’s general wellbeing to be as a result of the homes review of care practice and the resident’s ability to predict the sequence of events in their life, which had significantly improved their daily life. All residents have been registered with the Surrey Adult linked Disability Registers which will promote residents and staff to have additional links with various organisations and leisure/recreational opportunities. The general mealtime preparation, serving and support requirements of residents during their mealtimes were significantly improved. The home had purchased bright tablecloths, condiments, and crockery in addition to soft furnishings in the dining areas to make mealtimes more stimulating and a social event for the resident. Staff were genuinely interacting with residents at meal times and support given was attended in a sensitive and dignified manner. Brightly coloured menu boards have been developed for residents and are displayed in the home in order that residents know what meals are being served on the day. The home has developed a weekly plan for the resident’s activities, which are portrayed in photographs and include, painting, craftwork, cookery, going out and various games. Health care documentation for example visits to the doctor, dentist, and district nurse were observed to be well recorded and offered clear evidence that residents are encouraged and supported to attend appointments. In addition referrals for dietician support has been made on behalf of residents. The entrance to the home has been improved regarding the safety of people entering the building as handrails have been erected. The gardens have been improved and tidied, new sturdy garden furniture and bedding plants had been purchased to offer a comfortable and pleasing area for residents and their and their relatives and friends to use. The Registered Manager has undertaken a complete review of the provision of service to the resident. The review has included improved care for residents, with regard to their rights for value, choice, quality care and leisure activities. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 7 The overall décor and furnishings in the home had been improved to make the home more attractive and comfortable for the residents. The downstairs bathroom had been decorated which had significantly improved the room for residents to enjoy their bathing in a more r3estful and homely atmosphere. The inspector sampled staff files, which contained evidence of support, appraisal and supervision. The supervision and appraisal of staff was noted as an improvement following the last inspection. The home has implemented a Learning Opportunities Guide, which includes a training plan/log for staff to attend training. Staff improvements include a clearer understanding of their role, improved teamwork and sharing of skills, time management and improved staff morale. The staff told the inspector that they receive support and encouragement in their work by senior staff and the Registered Manager. The additional support recently implemented by the Registered Manager has included a weekly topic for discussion, which has increased enthusiasm and has assisted staff to contribute towards the aims and objectives of the home. What they could do better: A recommendation has been made that where residents do not choose to comply and have their medication in a private area for example their bedroom clear written documentation/risk assessment is implemented to explain the reasons why medication may have to be administered in a communal area in order to safe guard the resident and staff from any allegation of malpractice. The inspector has made a requirement that the staffing rotas are reviewed and developed to include the full staff members name and role, their contractual hours of work, the home shift patterns/times, the total of hours worked in the week, clear patterns of overtime and any current staff vacancy. Whilst some improvement has been made regarding the recruitment practices of the home requirements have been made. The inspector noted shortfalls in relation to the vetting of staff, including CRB’s employed by Wingreach Limited and Surrey Borders Partnership NHS Trust. During consultation with the Registered Manager the inspector was advised that application forms, interview notes and other related recruitment documentation is not forwarded to the Registered Manager from the human resources departments. The inspector noted that there was no formal induction for the home’s house keeping staff. A requirement has been made that housekeepers attend an induction programme, which includes the mandatory staff training of moving and lifting, first aid, and health and safety. A requirement has been made that the home must have clear distinctions regarding the implementation of the policies and procedures to safeguard residents and staff. The Registered Manager has implemented some new Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 8 policies and procedures devised by an external consultancy yet advised that he is not in receipt of updated policies and procedures related to the Surrey Borders Partnership NHS Trust. The home has a robust and clear procedure related to the weekly checking of the resident’s finances. The Registered Manager advised the inspector that there is no written policy and only trained staff members have direct access to resident’s money. The inspector has made a requirement that an in house written procedure regarding resident’s finances is developed and includes staff initials on the receipt following the purchase of goods in order to safeguard the residents and staff member. 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. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 9 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 Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The homes Statement of Purpose and Service User guide are written in order that prospective residents or their representatives have clear information regarding the care and facilities offered by the home. The admission and assessment procedure has been updated following the previous inspection and ensures that a prospective residents needs are fully assessed prior to moving into the home. EVIDENCE: The inspector sampled the reviewed admission procedure for one resident newly admitted to the home. The file contained personal information sheet, contact of family and friends and the terms and conditions of their stay which had been signed by the resident and their relative. The resident told the inspector ‘I’m on top of the world’ and that they were very happy living at the home and the staff were fantastic. The resident’s mother told the inspector that she was very relieved that her relative had settled so well and was so happy. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10. The home has made a concerted effort to improve the care planning and risk assessment documentation for people admitted to the home in order to ensure that their needs are met. All resident’s documentation is stored in the homes general office. EVIDENCE: The care plan evidenced by the inspector contained clear guidance for staff in supporting the person in their daily life and having an understanding of their particular abilities and disabilities. The documentation was colourful and stimulating and included a life plan map, which showed the persons support network of family, friends and health care professionals. Their likes and dislikes, medication details, their photograph, night care plan and risk assessments for various aspects of their life, including moving and handling. The Registered Manager explained that one resident had returned home from hospital with pressure sores and with staff support the pressure areas had been successfully treated. It was observed that the resident was also supplied with an air mattress and pressure-relieving cushion and had their feet elevated whilst sitting in their chair. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 12 Information regarding the residents is stored within the general office. During the inspection the inspector noted that the Registered Manager and staff were discreet regarding information of the residents within their daily work. All residents have been registered with the Surrey Adult linked Disability Registers which will promote residents and staff to have additional links with various organisations and leisure/recreational opportunities. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 13 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): 11,12,14,17. It was encouraging to note that the homes staff had made a concerted effort to develop a more holistic approach to the care of the residents and this was evidenced in the less clinical approach to care and a concentration on the leisure and interests of residents to offer quality time and stimulation. A marked improvement following the last inspection was noted in the preparation, presentation and support regarding the resident’s meals. EVIDENCE: The inspector noted that a care plan review regarding a resident newly admitted to the home included positive comments from the Care Manager. This illustrated the homes effective care in supporting the individual to become more independent for example a referral had been made to the Occupational Therapist regarding the use of a wheelchair and other medical referrals had been made in order to improve the residents daily life. On e comment card received from a relative stated ‘ my relative has made very good progress since being here. We (my family) are very happy with everything’. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 14 The inspector observed several residents throughout the home on the day of inspection being supported in leisure activities, which included arts and crafts, reading the daily paper, drawing and colouring, doing tapestry and listening to music and taking part in a sensory activity. It was encouraging to note that the homes staff had made a concerted effort to develop this more holistic approach to the care of the residents in offering quality time and stimulation. The inspector commented on the general improvement of one resident whose behaviour in the past inspections had been noted as unpredictable and unsettled. During the inspection the resident was calm and appeared to know the sequence of events in the home. The inspector concluded the improvement in the resident’s general wellbeing to be as a result of the homes review of care practice and the resident’s ability to predict the sequence of events in their life, which had significantly improved their daily life. The resident’s family member was visiting the home during the inspection and spoke highly of the care and support their relative continues to receive. A marked improvement following the last inspection was noted in the preparation, presentation and support regarding the resident’s meals. The previous inspection highlighted significant shortfalls and all the requirements made have been met within the agreed timescales. The inspector observed the breakfast and the lunchtime meal being prepared and served. It was encouraging to note that Wingreach Ltd had reemployed the chef, who had resigned several months ago. It was evident to the inspector through observation that the chef had maintained and developed significant links with the residents and encouraged them to make choices in regard to their dietary needs and likes. The dining areas of the home had both been improved to include a more homely atmosphere to include framed pictures, tablecloths, napkins and, condiments. The inspector observed that each resident had appropriate cutlery and were supported by staff in a genuine caring manner, which included conversations and encouragement. The home had purchased a hostess trolley in order to ensure that resident’s meals were served at the appropriate temperature. Brightly coloured menu boards had been developed for residents and are displayed in the home in order that residents know what meals are being served on the day. One resident had undertaken the responsibility of updating the weatherboard in the activities room. The Registered Manager advised the inspector that since the previous inspection the staff have undertaken a complete review of the provision of services of the home. As a result of the review some improvements have Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 15 included one resident each day being supported in the local community by a staff member. The inspector also noted that the homes vehicle had been repaired following the previous inspection, which also promoted residents access to activities and interests further a field. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 16 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): 18,19,20,21. The home has clear documentation to evidence each resident’s attendance to appointments with a variety of health care professionals. The medication procedure and practice was observed to be of a high professional standard. Staff promoted resident’s choice and privacy in order to ensure that each person is supported in an individual way. EVIDENCE: The care plans sampled evidenced clear documentation of each residents preferred choice in receiving personal care. One resident showed the inspector their new shirt and another commented that a staff member had supported her to have her hair coloured and her nails painted. Following requirements made during the last inspection the home has significantly improved the documentation regarding health care needs of the residents and the inspector sampled clear evidence in the form of a log that the resident had attended various health care appointments including speech and language therapy, medical clinics, specialised clinics and district nurse appointments. During the inspection the local GP arrived at the service and it was encouraging to note that the Registered Manager and staff had a positive and professional relationship with the GP. The GP spoke favourably of the Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 17 Registered Manager and staff and arranged to revisit the home the following week for consultations with the residents. On arrival at the home the inspector observed the Registered Manager undertake the administration of medication. The two medication trolleys (one for each floor) are stored in a locked room and secured to the wall. The Registered Manager explained that only trained staff members administer medication. The medication is provided in blister packs and each resident has their own administration sheets, which were evidenced as complete. Each resident individual section in the medication file included the persons photograph, their documented known allergies and preferred way to take their medication in order to ensure safety and respect of their choice. The inspector noted that one resident did not want to receive their medication in the privacy of their bedroom and staff discreetly administered the medication in the lounge area. A recommendation has been made that where residents do not choose to comply and have their medication in a private area for example their bedroom clear written documentation/risk assessment is implemented to explain the reasons why medication may have to be administered in a communal area in order to safe guard the resident and staff from any allegation of malpractice. The home has continued to closely support friends and relatives for people who have died whilst living at the home. All residents are encouraged to attend funerals of residents that have died if they choose to attend. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. The home has a complaints procedure and staff attend protection of vulnerable adults training to ensure the safety and protection of residents. EVIDENCE: The inspector noted that although some residents had speech and language difficulties staff members who actively listened to their views and opinions could understand them. The home has a complaints policy and procedure. Protection of vulnerable Adults training is included in the induction programme of the home. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 19 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): 24,25,26,27,28,30. The home offers a comfortable, safe, clean and homely environment for residents to reside. EVIDENCE: The overall décor and furnishings in the home had been significantly improved to make the home more attractive and comfortable for the residents. The improvements included the purchase of more homely items including framed pictures, stencilled walls in the corridors and new carpets. The laundry had been redecorated and net curtains purchased. One residents bedroom was being decorated, and the inspector was invited by several residents to look into their bedrooms all of which reflected the residents individuality, choice of décor and personal items including photos, pictures music centres, books, TV and other individual items. Each resident had a bed suitable to their needs with appropriate bed linen for their comfort. The downstairs bathroom had been decorated which had significantly improved the room for residents to enjoy their bathing in a more restful and homely atmosphere. The cleanliness the home was of a high standard. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 20 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): 33,34,35,36. The overall review of staffing practice with regard to the residents direct care have enabled the staff to work more effectively with the residents thus improving their quality of lifestyle. It was concerning to note that, as on previous inspections the home was not compliant with the Care Homes Regulations (as amended) 2001 regarding records to be stored within the Care Home related to the recruitment and selection of staff. EVIDENCE: During the inspection the inspector noted clear genuine interaction from staff to residents. Interventions of care were offered discreetly and in a dignified manner. The residents were observed to be relaxed and clam during the inspection and several residents told the inspectors that the staff were kind. The inspector spoke with several of the staff on duty including the housekeeping staff that told the inspector what training they had undertaken and the level of support and supervision they receive to help them in their work. The majority of staff had attended Care Plan training with an external facilitator to improve the staff understanding of resident care plans. The staff told the inspector that they receive support and encouragement in their work by senior staff and the Registered Manager. The additional support recently Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 21 implemented by the Registered Manager has included a weekly topic for discussion, which has increased staff morale, enthusiasm and has assisted them to contribute towards the aims and objectives of the home. The inspector sampled several staff files. Following requirements made in previous inspections the Registered Manager had improved the general record keeping and had ensured that some staff files were in compliance with the Care Homes Regulations (as amended) 2001. Several staff files did not contain the relevant documentation for example no application from, interview notes, current CRB related to Allied Care to evidence that vetting of staff had been made in order to ensure the safety and well being of residents. The Registered Manager explained that the Surrey Borders Partnership Trust undertakes the recruitment of care staff and the Trust keep the staff records. The inspector has made requirements that robust policies and procedures regarding recruitment and selection are maintained and all staff personnel files are stored within the care home and in accordance with the Care Homes Regulations (as amended) 2001. The inspector sampled staff files, which contained evidence of support, appraisal and supervision. The supervision and appraisal of staff was noted as an improvement following the last inspection. The home has implemented a Learning Opportunities Guide, which includes a training plan/log for staff to attend training. It was noted during the inspection of housekeeping staff files that there was no documentation regarding formalised induction training and the attendance of statutory training for example First Aid, Moving and Handling, Protection of Vulnerable Adults. The inspector has made a requirement that all staff working in the home must undertake a documented induction and all statutory training. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 22 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): 37,38,40,41. There have been significant improvements following the previous inspection regarding the overall management of the home. There remain shortfalls in the implementation of the homes policies and procedures, staffing rotas and resident finances and requirements have been made that these areas are improved within the timescales set. EVIDENCE: Following the previous inspection the Registered Manager has implemented a full review regarding the care and structure of the service. The review has included all staff and the Registered Manager explained that the revision of the tasks and workloads of staff has had a direct benefit to the residents as it enabled staff to support residents in activities outside of the home each day. The Registered Manager showed the inspector evidence that teaching sessions had been arranged in the home with regard to ‘valuing people’ which staff attend and complete a written questionnaire in order to demonstrate their understanding. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 23 One staff member spoken with during the inspection told the inspector that they receive ‘very good’ support from the Manager’s. Several staff commented that ‘things are much better now’. The Registered Manager is currently undertaking the Registered Managers Award, which he hopes to complete in March 2006. The inspector raised concern with the Registered Manager regarding the homes implementation of policies and procedures. The home currently has outdated policies and procedures from Bournewood (now Surrey Borders Partnership Trust) and a new set of policies and procedures from Allied Care. The Registered Manager advised the inspector that the Allied Care policies and procedures would only be pertinent to some staff as other staff were employed by Bournewood (now Surrey Borders Partnership Trust). A requirement has been made that the Registered Manager seek advise from the Registered Provider regarding the implementation of policies and procedures in order to ensure the smooth and robust operation of the home. The inspector sampled the staffing rotas and noted that the record illustrated that one staff member had worked excessive hours and the rotas did not clearly reflect the other details including the full staff members name, hours actually worked and contractual hours. The inspector has made a requirement that the rotas are an accurate account of the hours worked by staff and copy sent to CSCI local Eashing Office. The inspector sampled several resident’s cash tins, which were stored securely in the home. The cash tins contained the correct amount of money, which was cross-referenced with the records kept for each resident. The Registered Manager advised that only trained staff members had access to the resident’s cash tins, which are checked on a weekly basis. There was no written policy to detail the procedure of handling resident’s money and the inspector has made a requirement that this is implemented and includes the staff member’s initials on the receipt in order to be able to monitor expenditure and protect residents from any allegation of financial abuse. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 x 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 2 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Throwleigh Lodge Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 2 x x DS0000017648.V259703.R01.S.doc Version 5.0 Page 25 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 YA41 Regulation 17.2 Sch 4 9 13.(6) Requirement Timescale for action 21/10/05 2 YA40 3 YA40 4 YA35 The Registered Person must implement a written policy to detail the procedure of handling resident’s money in order to be able to monitor expenditure and protect residents from any allegation of financial abuse. 17.(2) Sch 4 The Registered Person must ensure that the rotas are an accurate account of the hours worked by staff and a copy of the improved rota sent to CSCI. 12.(1)(a)13.(6) The Registered Manager must seek advice from the Registered Provider regarding the implementation of policies and procedures in order to ensure the smooth and robust operation of the home. 18.(1)c (i) The Registered Person must ensure that all staff, including housekeeping staff undertake an induction programme and all statutory training to assist them in the work they are to perform. DS0000017648.V259703.R01.S.doc 13/01/06 13/01/06 13/01/06 Throwleigh Lodge Version 5.0 Page 26 5 YA34 19.(1)(a-c) 5.(a-d) The Registered Person must ensure that robust policies and procedures regarding recruitment and selection are maintained and all staff personnel files contain documented evidence of vetting in order to protect service users. 13/01/06 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 Refer to Standard YA20 Good Practice Recommendations Where residents do not choose to comply and have their medication in a private area for example their bedroom clear written documentation/risk assessment is implemented to explain the reasons why medication may have to be administered in a communal area in order to safe guard the resident and staff from any allegation of malpractice. Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Throwleigh Lodge DS0000017648.V259703.R01.S.doc Version 5.0 Page 28 - 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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