Inspection on 14/04/05 for Throwleigh Lodge

This inspection was carried out on 14th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Throwleigh Lodge 10/11/08

Throwleigh Lodge 28/11/07

Throwleigh Lodge 20/02/07

Throwleigh Lodge 13/10/05

Throwleigh Lodge 23/09/04

Throwleigh Lodge 13/05/04

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Southfields

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33 St John`s Church Road

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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 GU21 4QR Lead Inspector Ms S Magnier Unannounced 14 April 2005 08.00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Throwleigh Lodge Address The Ridgeway Horsell Woking Surrey GU21 4QR 01483 772901 01483 740569 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) Wingreach Limited Mr Hassam Gora Soliman CRH Care Home 17 Category(ies) of LD Learning Disability, 17 registration, with number of places Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The age range of persons accomodated will be 40 - 65 years Date of last inspection 23 September 2004 Brief Description of the Service: Throwleigh Lodge is a large detached property set in a quiet residental area close to Woking town centre. Care is provided to seventeen men and women who have learning difficulties, some of whom may require nursing care. Accomodaton is arranged over two units one on the ground floor and the other on the fisrt floor. Each floor has communal areas, bedrooms and bathrooms. The main office and kitchen are situated on the groud floor. The home has a garden at the rear and ample off street parking at the front of the building. The care staff of the home are managed and sub-contracted by the NHS Trust. The Registered Manager, catering department and housekeeping staff are employed by Wingreach Limited. The overall care responsibility of the home is overseen by Surrey Borders Partnership NHS Trust. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours by 2 inspectors. Several residents were able to tell the inspectors how they felt living at Throwleigh Lodge. For others this was difficult due to their individual communication difficulties. Spending the day at Throwleigh Lodge gave people the opportunity to speak with the inspectors and for the inspectors to look around the home and at the paperwork in the office. During the day the inspectors looked around the home, watched breakfast and lunchtime meals being served, looked at the paperwork in the office and talked with the Manager and staff. No visitors were available but comment cards for them and others people who visit the home were left for people to write on and send back to the inspectors. The inspector left some cards for the residents to complete. What the service does well: What has improved since the last inspection? The home has improved in the writing of the residents care plans and risk assessments. The area of the garden has been improved to make it safer for residents to use. One bathroom has been decorated and some carpets have been replaced. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 6 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. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 34, and 5 The arrangements for the assessment and admission process of residents to the home must be improved. EVIDENCE: The care plan seen for a resident newly moved to the home was incomplete and did not contain the following • There was no evidence that the resident had an individual written contract or statement of the terms and conditions of the home. • A diagnosis of the resident’s needs and health care matters. • No next of kin recorded. • Details of any specialist communication needs of the resident and methods of communication that may be appropriate to the resident to assist in their daily lives. • A risk assessment related to any behaviours of the resident that may challenge the service. • No moving and handling risk assessment for the resident. • No records available on admission for the residents medication needs. Requirements have been made under Regulation 12.(1)(a)(2)(3) the Care Homes Regulations (as amended) 2001 to meet the major shortfalls identified of the admission procedure to the home. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 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 standard(s) 6,7, 8 and 9 There was no clear evidence that all residents had been consulted about their care plans and preference in their lifestyles or had any opportunity to contribute to the way in which their home is run. EVIDENCE: All persons resident in the home had a documented care plan and a book for staff to write in each day detailing the events of the day. The care plans seen, which had been recently updated, did not include any evidence that residents had taken part or were consulted in the plan of their care. The care plans were not signed by the residents or their representatives. One resident had agreed working practices and goals, which they were waiting in their room to share with their key worker. It was evident for this resident that staff were working alongside them to support their needs in a specific area of care. The home has improved the documentation of risk assessments, however there was little evidence seen to demonstrate that residents were aware of the documented risks in order to promote independence and control over their lives in their home. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 10 The home employs a housekeeper and it was not observed that the residents were involved in cleaning their rooms, assisting with dusting, meal preparation or laying the dining room tables. One resident said the housekeeper ‘does all the cleaning and hovering’ and ‘I used to make the teas when I was better’. The home currently supports people with nursing needs. A balance between the nursing and residential care provided needs to be reviewed in order that residents care is provided in a more holistic manner to meet their individual aspirations and goals. Requirements have been made under Regulation 17(1)(a) and Schedule 3 of the Care Homes Regulations (as amended) 2001 to meet the major shortfalls in meeting the holistic needs of the residents through a further improved care planning and risk assessment process and inclusion of residents within their home. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15 and 17 The arrangements for resident’s meals were institutional, inadequate and concerning. The arrangements for residents to engage in local social and community activities need to be improved and opportunities for personal development and participation to improve resident’s quality of life could be implemented. EVIDENCE: Observations were made during the serving of the midday meal, which have raised serious concern and were as follows MEALTIMES • • Staff responsible for meal preparation and delivery lacked sufficient language skills, training and awareness to ensure the needs of the residents were met. One resident sitting at the table waiting for breakfast had his arm caught in the lap strap. H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 12 Throwleigh Lodge • • • • • • • Lunch was served to the dining room on a trolley from the main kitchen and although covered by a Perspex cover one resident waited 20 minutes for staff assistance with their meal and no awareness was made that the meal may be cold or may need reheating. One staff member was observed to cut a residents meal with a spoon. Little or no interaction took place with residents by staff. A staff member served each resident crockery of a single spoon from a dishwasher container to the dining table. Residents were supported with their meal by staff members standing or leaning on the table, which did not reflect dignity and respect and appropriate support for residents. The dining tables lacked any condiments or other table wear or napkins and generally the dining areas were void of a homely atmosphere for residents to enjoy their meal. Drinks were prepared following the meal, which indicated that residents were not given choice by asking what may be their preference. One resident said ‘staff make the drinks’. One resident was constantly walking up and down the corridor after staff hoping that breakfast was going to be served. Although the resident had limited communication it was evident the word ‘tea’ was being spoken and signed by the resident touching their lips. Staff response to the resident was ‘in a minute’ which lasted 10 minutes before the resident finally had a cup of tea. It is recommended that the Registered Manager review the structure of the morning routine in order that the home can meet the needs of the residents rather than the residents fitting in with the homes routines. Whilst observing the meal on the first floor it was evident that residents and staff were unsure what the meal was and some discussion took place with a resident and staff member ‘ what does it look like’ and ‘what do you think it is’? When asked by an inspector about the menu one member of staff responded by saying ‘I don’t know if we have a current menu’ and ‘sometimes it not what is on the menu’ e.g. food served. The utensils used by some residents were inappropriate to their needs and there was a noticeable lack of communication between staff and residents. One resident told the inspector that ‘the food is ok but if I don’t like a meal some staff will give me something else but some wont and they sometimes get funny’. Requirements have been made under the Care Homes Regulations (as amended) 2001 and a letter of serious concern detailing requirements for improvement have been made that the Manager improve and review the way in which the preparation, serving and support requirements of all residents during mealtime is undertaken. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 13 OPPORTUNITIES, PARTICIPATION AND ACTIVITIES. The home is currently advertising for an activity coordinator and there are a variety of board games, jigsaws, Karaoke and Bingo that residents can participate in with staff members. The Activity rooms had photos and paintings displayed which resident’s had been involved with. One resident said ‘I’ve made strawberry jam and we picked the strawberries’, ‘Ive got drawing books and colouring pens’. ‘We went on holiday last year, to a holiday camp it was nice, I used a wheelchair but I haven’t used it since’. Whilst staff endeavour to support residents in the home with leisure activities several resident activity plans were sampled and there was areas which could be improved for example one resident in particular with specific needs had not been supported out of the home into the local community for a significant amount of days. This lack of structure and opportunity fails to offer predictability, consistency and opportunity for residents to have fulfilling and appropriate activities within and outside of their home. Staff support residents to use the sensory room although staff said they had not received any training to use the equipment and have learnt from each other what to do. Residents spoken with made the following comments about activities ‘ when (name) was here we used to make cakes’ and ‘I used to go out with (name) and have a cup of tea I don’t do that anymore as (name) not here’ ‘Id like to get out more’ ‘I like living here as I do lots of things for myself in the activity room’, The home enables residents to keep in contact with their family and friends and one resident said ‘ I was a bridesmaid for my sister last year’ ‘There’s been two funerals since you’ve been here and I’ve been to their funerals’. The home has a vehicle for the residents to use however a large hole in the roof of the vehicle was observed and covered with a plastic draw sheet. The Manager said that another vehicle was available. A recommendation has been made that the vehicle is repaired without delay in order that the residents can use it with staff support. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 14 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 standard(s) 18 and 19 The arrangements for the documentation of the preferences and wishes of the residents with regard to their general health care needs could be improved. EVIDENCE: The residents who had been supported by staff to get up in the morning were appropriately dressed and attention given to their appearance. The preferences and health care records of several care plans identified some shortfalls, which included • Lack of correspondence on the care plan to the daily records. • Weight chart not current • No dental record or reason for lack of consultation with dentist. • No other evidence of health care intervention e.g. checks with General Practitioner. In each residents room is a small discreet box file, for staff to refer to containing specific details about the residents personal care needs, communication skills, likes and dislikes and ways in which they wish to be supported in moving and lifting. From observations in the home and talking to staff only one resident had had a bath on the morning of the inspection as according to staff the residents have Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 15 a bath in the evening although this preference was not reflected in the care plan. Actions have been required by the CSCI and are detailed on Page 27. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 16 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 standard(s) N/A Not assessed on this occasion EVIDENCE: Not assessed on this occasion Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 17 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 standard(s) 24,25,26,27,28,29,30 The home generally provides a homely comfortable environment for residents although some improvements throughout the home could be made. EVIDENCE: The home generally offers a homely comfortable environment for the residents. Each resident room reflects the interests; choice and preferences of the resident and personal belongings were evident. The bedroom furniture was good quality and the rooms were generally clean and tidy. Specialist furniture e.g. chairs and wheelchairs, walking frames, portable hoists were observed throughout the home. Portable hoists had been recently serviced in addition to the fire extinguishers. One resident said ‘If I want to use the toilet it is near my room’ and another resident stated ‘I like my room’. Several residents’ beds had only a duvet cover without a duvet and two bedrooms had no curtains. If this is the preferred choice of residents these Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 18 choices must be documented in the residents care plan in order to ensure that the home is providing suitable and adequate bed linen and furnishings for the residents comfort. One bathroom had been thoughtfully decorated. The additional 2 bathrooms and toilets need to be redecorated to reflect a more homely and less clinical atmosphere for the residents. Although the lounge areas were thoughtfully decorated the lay out of the armchairs (which were situated along the walls) gave both the lounges an institutional feel. A recommendation has been made that the Manager and staff consider, in consultation with the residents ways in which the lounge areas can be made more relaxing and enable residents to sit in smaller groups so they can talk with each other. A lounge table had been left in the lounge covered in bubble wrap and staff were not aware what the table was for. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 It was concerning that the home was not compliant with the Care Homes Regulations (as amended) 2001 regarding the recruitment, selection and training for staff as this has been an historical issue. It is imperative that the Registered Providers and Registered Manager comply with the Regulations in order to ensure that residents are protected and provided with staff trained to meet their needs. EVIDENCE: The staff spoken with during the inspection said they had received various training to support the residents. The personnel files of the staff on duty were seen and the following observations made: • A number of application forms were incomplete of employment history, qualifications and experience, past training, next of kin details and GP contact and a staff member had not signed the Rehabilitation of Offenders Act section of the application form. No current training records were available. A number of staff files only had one reference. References were not from the previous employment or a professional person. H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 20 • • • Throwleigh Lodge • • • • • • A number of staff files did not contain evidence of Criminal Disclosure checks. Some files showed no visas or eligibility to work in the United Kingdom. Several staff files did not contain recent photographic proof of identity. No files were located for the appointment of the person cooking the meals served at the home on the day of inspection. No file was located for the visiting aroma therapist who has been employed to work in the home with residents on a one to one basis. No file was located for a Bank member of staff. All Staff personnel and training records, including the Registered Manager must be available within the home for inspection and a requirement has been made by the CSCI that the home attends to this matter. Some staff spoken with said they were happy working in the home yet ‘there’s not enough staff if there is staff sickness’ and ‘where we have a chance we have staff meetings’ and ‘sometimes I have supervision.’ ‘I like it it’s a job’. Staff were observed to be hardworking and committed to providing the best care to the residents yet it was observed that several lacked sufficient language skills, training and awareness to ensure the needs of the residents were met. A resident said ‘I like all of the staff’ and ‘I’m looked after very well’ Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,42,43 It was concerning to observe the general lack of management and leadership in the home. The service needs to review its current position with regard to the detail of the inspection report and action must be taken to rectify the major shortfalls. EVIDENCE: During the inspection of the premises the following shortfalls were identified and requirements have been made that these hazards are rectified to ensure the safety and wellbeing of the residents: • • On arrival to the home it was noted that the Clinical waste bin in the car park was full and the lid had not been secured. Procedures must be in place for the prompt collection and storage of clinical waste. Leading to the front door of the home is a ramp and on either side no rails have been sited. This is a potential hazard to any one coming into the home and rails must be in place without delay. H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 22 Throwleigh Lodge • • • • • • • • • • • • • • • • • • • • Extractor fans in the upstairs bathroom need cleaning, as they may be hazardous. Several Fire doors within the home were not closing properly and must be repaired immediately. The Fire extinguisher on the top floor requires replacing immediately. The water leak to ceiling in the office needs to be repaired and decorated. The hazard tape noted over the join on the downstairs carpet needs to be removed and carpet repaired or replaced. A soiled incontinence pad and sheet from the residents bed was noted in a waste bin and the Manager must review the homes infection control policy and forward a copy to CSCI local office. One resident’s room had a strong offensive odour and the Manager must make adequate arrangements for the control of odours and carpet cleaning is to be maintained. Key locks on resident’s furniture must be in working order to ensure that residents have a lockable space within their rooms. The upstairs kitchen fridge and freezer require de-frosting. The main kitchen oven was dirty and needs cleaning. Opened food packages stored in the fridge were not dated and labelled. A red chopping board must be made available in the upstairs kitchen. The First aid box was stored behind the window fly screens in the upstairs kitchen and was not easily reached in the event of an emergency. The work surface in the upstairs kitchen was been damaged and requires replacing. The bolt to the upstairs laundry room was broken and a hazard to the resident’s. Washing machine tablets were left in an unlocked drawer in the Laundry and these must be secured at all times in compliance with the Control of Substances Hazardous to Health legislation. One resident’s wheelchair was dirty and needed cleaning. In one resident’s room the wall clock had stopped. It is important that staff are aware of the significance of these matter in order to help residents have their own knowledge and awareness in their daily lives. No hand towel bin was found in the downstairs toilet and this must be provided. Maintenance to the seals surrounding the bath and toilet cistern in the downstairs bathroom need to be repaired to avoid injury by the sharp tiles. During the inspection the Registered Manager requested that the Deputy Manager, who had been on night duty remain in the service. The inspectors advised that this was not appropriate for the staff member to be in the service in view of her recently completing a night duty. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 23 The Registered Provider is currently not attending the home on a monthly basis under Regulation 26 of the Care Homes Regulations 2001 (as amended). These visits must commence in March 2005 and completed reports sent to CSCI Local Office at Eashing. Details of the report contents have been supplied to the Registered Manager at the time of the inspection. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 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 2 2 2 2 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 1 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 2 3 3 Standard No 11 12 13 14 15 16 17 2 2 1 1 1 x 1 Standard No 31 32 33 34 35 36 Score 3 3 2 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Throwleigh Lodge Score 2 2 x x Standard No 37 38 39 40 41 42 43 Score 1 1 1 x x 1 1 H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 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 2,3,5 Regulation 12.(1)(a) (2) (3) Requirement The Registered Manager must make sure that suitable arrangements for the admission and assessment of residents is undertaken in order to promote and make provision for the health and welfare of residents. A copy of the homes admission and assessment procedure must be forwarded to CSCI local offfice. The Registered Manager must ensure that all residents care plans, risk assessments and any subsequent revision of care is available to the resident and/or thier representaive. The Registered Manager must ensure that risk assessments are documented with residents in order to promote independence and safety for residents in their home. The Registered Manager must ensure that the preparation and serving of resident’s meals is conducted in a manner that respects the dignity of residents. The Registered Manager must ensure that sufficient appropriate crockery and cutlery Timescale for action 14.5.05 2. 6 15.(2)(a)( c) 14.5.05 3. 9 4.(a)(b)(c ) 14.5.05 4. 17 12.(4)(a) 15.4.05 5. 17 16.(2)(g)( i) 15.4.05 Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 26 6. 17 16.(2)(i) 7. 17 17.2.Sch 4.(13) 8. 17 12.(1)(a)( b) 14.(1)(a) 9. 17 12.(1)(a)( b) 14.(1)(a) 10. 13,14 16.(2)(n) is available to residents and that meals provided are suitable, wholesome and nutrious to meet the needs and choice. The Resgistered Manager must ensure that liquidised or soft diets provided must be reviewed to ensure that it is not provided in an unapetising manner and details of a dietician plan is in place within the residents care plan. The Registered Manager must ensure that a record of food provided e.g. menu must be maintained in sufficient detail (large print) and available to residents and staff on a weekly basis to offer choice and discussion with residents and to enable any person inspecting the record to determine whether the diet is satisfactory. The Registered Manager must seek professional advise and support from the Occupational Therapy, Dietician and Speech and Language therapy departments which includes an assessment of the resident needs and staff code of practice in relation to mealtimes. The Registered Manager must ensure that all staff supporting residents at mealtimes are suitably competent and trained. This must include awareness of residents needs including the level of support and equipment required by them at mealtimes. It is recommended that the Occupational Therapist be consulted regarding this matter. The Registered Manager must ensure that leisure activities for residents must be addressed in order to provide residents with appropriate stimulation, 15.4.05 22.4.05 14.6.05 14.6.05 14.6.05 Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 27 11. 19 12. 24 13. 14. 28 32 15. 34 16. 35 17. 36 engagenment and further development to meet their aspirations and goals. 13.(1)(b) The Registered Manager must make arrangements for residents to receive treatment and advice where appropriate, and other services from any health care professional. 16(2) The Registered Manager must provide adequate bedding and other furnishings including curtains suitable to the needs of the resident. 23.(2)(d) The Registered Manager must ensure that all parts of the home are reasonably decorated. 18.(1)(a) The Registered Manager must ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers that are appropriate to the health and welfare of residents. 7,9,19. The Registered Provider and Schedule Manager must ensure that all pre 2 employment checks, including Bank staff, are carried out prior to staff commencing employment at the home, this must include the visiting aromatherapist and any other persons in one to one contact with the residents. 18.(1)(c) i The Registered Provider and Manager must ensure that staff, including the Registered Manager receive training appropriate to the work they are to perform, including structured induction training and training arranged in relation to communication, including methods used by residents for example pictorial books and Makaton (sign language). 18.(2)(a) The Registered Manager must commence formal supervision for H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc 14.6.05 21.4.05 14.6.05 14.6.05 28.4.05 28.4.05 16.5.05 Page 28 Throwleigh Lodge Version 1.30 18. 37 26.(1)(2)( 3)(4)(a)(b )(c)(5)(a) (b)(c) 23.(4)(c (i)(iv) 19. 42 20. 42 23.(4)(c (i)(iv) 16(2)(j)(k ) 21. 42 22. 42 16.(2)(j)( k) 12.(5)(b) 23. 38 24. 42 13.(3)(4)( a) all staff (management,senior,care staff, cook, aromatherapist) which must provide them with a forum to discuss practice and training needs. This meeting must be recorded and must be provided at least six times per year. The Responsible Individual must visit the care home (unannounced) on a monthly basis and a written report must be sent to CSCI local Eashing office. The Registered Manager must ensure that the fire doors which were not closing properly are repaired and fire fighting equipment is in sound working order or replaced The Registered Manager must ensure that the fire extinguisher which was not working be replaced. The Registered Manager must keep the home free from offensive odours and make suitable arrangements for the disposal of clinical waste. The Registered Manager must forward a copy of the home Infection Control procedure to the local CSCI Eashing office. The Registered Manager must encorage and assist staff to maintain good personal and professional realationships with residents. The Registered Manager must monitor the safe practice of the Control of Substances Hazardous to Health and storage Regulations. 16.5.05 Immediate Immediate 28.4.05 5.5.05 21.4.05 21.4.05 Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 29 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 13 28 Good Practice Recommendations The damaged vehicle must be repaired as soon as possible. For the Manager and staff to talk with the residents to ask if they would like to make the lounge areas in home more relaxing and possibly to sit in smaller groups so they can talk with each other. Throwleigh Lodge H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrrey GU7 2Q 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 H58_s17648_Throwleigh Lodge_v219750_140405 Stage 4.doc Version 1.30 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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