Inspection on 28/11/07 for Throwleigh Lodge

This inspection was carried out on 28th November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 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 20/02/07

Throwleigh Lodge 13/10/05

Throwleigh Lodge 14/04/05

Throwleigh Lodge 23/09/04

Throwleigh Lodge 13/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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 Sandra Holland Unannounced Inspection 28th November 2007 11:00 Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 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.V356260.R01.S.doc Version 5.2 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.V356260.R01.S.doc Version 5.2 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.V356260.R01.S.doc Version 5.2 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. 20th February 2007 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. Accommodation and care can be provided for up to seventeen people who have learning difficulties, some of who may require nursing care. Accommodation is arranged over two floors, with each floor consisting of a lounge, dining areas, bedrooms, bathrooms and toilets. The home also has an activity room, 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 there is off street parking at the front of the building. Wingreach Limited is the registered provider of the service and employs the Registered Manager and catering and housekeeping staff. Surrey and Borders Partnership NHS Trust employ the care staff who work at the home. The fees at this service range from £1100.00 per week to £1400.00 per week. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI), under the Inspecting for Better Lives process. A full analysis of all information held about the home, was carried out before the visit took place. Mrs Sandra Holland, Regulation Inspector carried out the site visit over seven and a quarter hours. Mr Hassam Soliman, Registered Manager was present representing the service. A tour of most areas of the home was carried out and a number of records and documents were sampled, including residents’ individual plans, medication administration records and staff recruitment and training files. Six residents, one visitor and eight staff were spoken with during the course of the visit. An Annual Quality Assurance Assessment (AQAA) was supplied to the home. This was completed and returned and some of the information provided will be referred to in this report. Information supplied in the AQAA stated that equality and diversity are promoted in the home by making sure “all staff members are fully aware and support the free expression of our service users”. “Information on all aspects of equality and diversity for our service users are provided to staff during their induction training and is freely made available to staff who may wish to refresh their training at a later date”. Service users attend places of worship of their choice on a weekly basis and a vicar visits the home once a month. “Equality and diversity is also strongly supported for all members of staff”. A number of residents were not able to give their views about the home due to their communication difficulties. Where this was the case, residents’ responses were assessed by observation of their body language, facial expressions and interactions with staff. The inspector would like to thank residents and staff for their hospitality, time and assistance. What the service does well: Provides a high level of individual care and support to a group of residents who have a wide range of needs. Detailed individual plans have been drawn up to give staff effective guidance about the care and support they need to provide to meet the needs of residents. A “snapshot” summary of the plan is provided in residents’ rooms Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 6 for staff to refer to, and these would be particularly useful to new or temporary staff. Residents are offered a variety of social and leisure activities and are supported to take part in, and enjoy these, both at home and in the community. A varied menu is offered to residents and meals are served in dining rooms that are attractively presented. Meals are adapted to meet residents’ needs, such as pureed, and each item was pureed separately to ensure residents could identify and taste these. The home is decorated and furnished to a high standard and appears to provide residents with a comfortable place in which to live. All parts of the home were very clean and freshly aired, which gave no indication of the high level of needs of many residents. What has improved since the last inspection? What they could do better: It is recommended that the assessment of residents’ needs which is carried out before they move into the home should be signed and dated, to make clear who carried out the assessment and when. Residents must be provided with a contract of a statement of the terms and conditions for living at the home. All records relating to residents should be kept in their individual plan to ensure they are used in a person centred way and are fully available to staff. Staff must receive training in the safeguarding of adults. Assessments should be carried out of the residents’ vulnerability to financial abuse or exploitation and the home’s policy and procedure regarding abuse should be reviewed. Staff must receive induction training and a record of this must be kept in the home. The induction record should be signed and dated by the member of staff and the supervisor, to confirm who was involved and when it was carried out. Staff must receive training required by law (mandatory) and other training, appropriate to their role. The hours worked by the manager must be reviewed to safeguard the health, safety and welfare of residents, and of the manager himself. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 7 A review must be carried out of the quality of the service provided and this must involve the residents and their representatives. It should also involve others involved in the support of residents, such as healthcare and social care professionals. Visits to the home under Regulation 26 must be carried out and the reports written must be kept in the home. Further details of Regulation 26 visits are given at Standard 39, which relates to quality assurance. The staff rota must be maintained as an accurate record of persons working in the home and whether the hours allocated to staff were actually worked. 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. The summary of this inspection report can be made available in other formats on request. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 8 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.V356260.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents were assessed before they moved into the home, to enable the home to know if they could meet the resident’s needs. Residents were offered the opportunity to make trial visits, to be sure the home would suit them. The majority of residents have not been provided with a contract informing them of the terms and conditions for living at the home, so most residents are not aware of these. EVIDENCE: The manager advised that the majority of residents moved into the home when it opened ten years ago, although a small number of residents have moved in during the past year. The files of a number of residents were sampled, including those of residents who have moved into the home more recently. A detailed assessment of the needs of prospective residents had been carried out, usually by the manager, deputy manager or both. It was noted that the pre-admission assessments for three residents had not been dated, so it is not possible to know exactly when these were carried out. One pre-admission assessment had not been signed, and it was noted that the assessment forms make no provision for a signature. It is recommended that all assessments of Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 10 prospective residents are signed and dated, to clearly show who has carried out the assessment and when. The assessments had been carried out wherever the prospective resident was living, and for two residents this was in hospital. Wherever possible, residents have been invited to visit the home, to see if it suited them, the manager stated. Records that were seen confirmed that a resident had come to the home for a short stay, and liked it so much they had decided to continue living there. Information supplied in the AQAA indicated that all residents living at the home are receiving financial support from a council or health trust. The AQAA stated that only two residents have a copy of the agreement specifying the arrangements for living at the home. This was confirmed at the time of inspection, as of the three individual files sampled, only two had a contract or statement of the terms and conditions for living at the home. This means that the majority of the residents have not been provided with the information about the fees that are being paid on their behalf, what services should be provided by the home and what obligations residents are living under, such as the notice period, if they wish to leave. A requirement has been made regarding Standard 5, that each resident must be supplied with a contract or a copy of the statement of the terms and conditions for living at the home. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed individual plans have been drawn up to effectively guide staff to the care and support needs of residents. Residents are encouraged and supported to make their own decisions and to take assessed risks, to enable them to be as independent as possible. EVIDENCE: As previously mentioned, the individual plans of three residents were sampled. These contained comprehensive information about each resident’s needs, and provide staff with effective guidance as to the care and support required to meet those needs. The individual plans covered all aspects of residents’ daily lives, including their communication methods or needs, mobility, personal care, activities and leisure, eating and drinking and night-time needs. Residents’ individual plans had been reviewed and updated regularly, to ensure they accurately reflect residents’ current and changing needs. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 12 It was very positive to note that residents keep a copy of their individual plan and a separate summary of the plan, in their bedroom. The summary provides new or temporary staff, with an accurate and effective snapshot of each resident’s needs and how to meet these needs. Some aspects of the individual plans were written from the residents’ viewpoint, such as “things I like” and “things I don’t like”, but from speaking to staff it was apparent that some records, such as the weight of residents, are recorded in separate folders. It is recommended that all information relating to residents is included in the individual plan, as this is more person centred and reduces the risk of confidentiality being breached. Residents who were able, advised that they are encouraged and supported to make their own choices and decisions. A resident happily showed their bedroom and spoke of choosing the colour for the decoration. A group of residents were enjoying their own choice of activities during the course of the inspection visit. Where risks to the health, safety or welfare of residents have been identified, these have been assessed and recorded, including any actions that need to be taken to minimise the risks. These included the risks associated with mobility and falling, the use of bed rails and wheelchairs, choking, developing pressure sores and being moved or handled. Risk assessments had been regularly reviewed and revised to ensure they accurately reflect the current level of risk. It was positive to note that a nutritional risk to a resident had moved from high risk to low risk during the time they were living at the home. Information supplied in the AQAA stated that residents are encouraged to take calculated risks, to live as normal a lifestyle as possible. . Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are actively supported to take part in a wide range of social and leisure activities and to maintain contact with their families and friends. Well balanced and varied meals are offered to residents, and these are served in attractive dining rooms. EVIDENCE: From speaking to residents and a visitor, and all the information seen and provided, it was clear that residents are supported to follow their own interests and to take part in a wide variety of social and leisure activities. A resident was spoken with on their return from a visit to the local library, and they told of bringing books home to enjoy. Other residents have daily papers delivered as they enjoy reading them and keeping up with current affairs. A number of residents are artistically talented. One resident is very Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 14 accomplished at embroidery and another completes very attractive pictures, and both residents were happy to show items that they had produced. Information supplied in the AQAA stated that staff are dedicated to maximising residents’ involvement in a variety of activities, even though due to their needs, they may not be able to participate fully. This includes taking part in painting, cooking, shopping, and outings to the countryside or seaside. A well equipped activities room is available on each floor of the home, to enable residents to take part in art and craft sessions, games and jigsaws. A sensory room is available to residents who wish to relax or who are less able to take part in more active events. This has a music system and a variety of items to stimulate the senses, including a bubble column, a coloured light display and a massage mat. It was clear that residents are actively encouraged and supported to maintain contact with their families and friends. A resident happily told of going to visit members of their family, whom they had not seen for a number of years. Staff advised that residents have recently been supported to organise Christmas gifts and cards to give to their families and friends. Residents were observed taking part in the day to day running of the home, helping to lay tables for lunch and helping to clear away afterwards. Lunch was served in a number of dining rooms, each furnished to suit a different number of residents. The dining rooms were attractively set with tablecloths and flowers. Staff advised that some residents prefer company at meal times, but others prefer to be more alone and quiet, and these choices are respected and accommodated. It was positive to observe that residents are encouraged to be as independent as possible when eating and drinking. A number of aids, such as adapted china and cutlery were provided to enable residents to manage their meal. Meals were provided in alternative forms, such as pureed, if required and staff maintained a discreet presence, but were available to assist residents if needed. Staff advised that a four week menu plan is followed and this was seen to be varied and well balanced. Specialist diets can be accommodated and currently diabetic diets and soft or pureed diets are being provided. It was positive to see that each item within pureed meals had been pureed separately, to ensure they retained their colour and appeared appetising. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in the way that they prefer. The administration of medication is appropriately managed and residents’ healthcare needs are well met. EVIDENCE: Staff advised that residents are supported in the way they prefer wherever possible and are offered support, although encouraged to be independent. If a resident wished to remain in bed in the morning for example, staff advised that they would offer to support to other residents first and come back later to the resident who wanted to have a lie-in. Residents’ likes and dislikes have been recorded in their individual plans, to assist and guide staff when providing care and support. These included comments such as “I like jewellery”, “I don’t like staying up late”, and “I don’t like too much noise”. It was clear from the records seen and speaking to residents and staff, that residents’ healthcare needs are well met, and a number of healthcare professionals are involved in the support of residents. These include general Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 16 practitioners (GP’s), dentist, chiropodist, optician, psychiatrist and hospital specialists. Staff advised that if a change is noted in the health of a resident, a referral is quickly made to the GP, to ensure that medical or other advice is promptly sought. Staff advised that medication is provided to the home by a national pharmacy chain. Medication is supplied in “blister” packs, with each blister containing an individual dose of medication. This is designed to ensure a safer system of administering medication and more effective monitoring of the stock held. Medication was seen to be stored appropriately in a secure provision. A lockable medication fridge was available for items requiring chilled storage. A member of staff advised that they order medication, along with the manager, and they take the lead in checking in medication when new stocks are received. The medication procedure was seen to have been recently reviewed and was accessible to staff. It was positive to note that detailed information had been prepared, to advise staff of each residents’ preferred method of taking their medication. The amounts of a number of medications held were randomly checked with the records held and these accurately matched. It was noted that the amount of medication held in stock which has been prescribed for “as required” administration, had not been carried forward from one medication administration record (MAR) chart to another, although space is provided on the MAR chart for this. This makes it difficult to check the amounts that should be present and it is recommended that any stock held is “carried forward”, for safer and easier monitoring. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents who are able, know who to speak to if they are unhappy. Only one complaint has been received and that has been appropriately managed. Staff need to receive safeguarding adults training to ensure they are aware of the correct actions to take if abuse is suspected or alleged. EVIDENCE: The home’s complaints procedure has been produced in an easy read format and has been supplied to each resident. The procedure is included in the residents’ plans, which are held in their bedrooms. Resident who were spoken with, advised that they would speak to the manager or their key-worker if they were unhappy about anything. Information supplied in the AQAA indicated that only one complaint had been received in the past year and that was not upheld. No information has been received by CSCI regarding any complaint made to the home. The AQAA also stated that residents, their representatives and staff are all aware of the complaints procedure, and that staff work hard to gain the trust of residents and are open to any concerns residents may have. It was clear from observing residents and from the AQAA, that a number of residents are not able to express any concerns, and would have to rely on staff or others, to recognise that they were unhappy or distressed. Staff advised that they are aware of each resident’s usual behaviours and how they express Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 18 their mood, and would be able to recognise changes to these. If a change was noted, staff would look for the reason for this and refer it to the manager or person in charge, they stated. The home has its own policy and procedure regarding abuse, entitled “Protection and Prevention of abuse”. This was seen to link with the home’s whistle-blowing policy and procedure. It was noted that the Protection and Prevention of abuse policy needs to be reviewed and revised, as it made no mention of contacting police immediately, if a crime was suspected. The policy also refers to CSCI making the decision about who should investigate complaints or allegations, but this is not the role of CSCI. The manager stated that in the event of a suspicion or allegation of abuse, the home would follow the Surrey Multi-Agency procedure for Safeguarding Adults (formerly Protection Of Vulnerable Adults - POVA). An up to date copy of the procedure is kept in the home for staff to refer to if needed. Three staff were spoken with regarding what action they would take if they had any concerns about residents. Two staff were clear that they would report this to the manager or person in charge, but one member of staff was not so clear and did not seem to fully understand what abuse means. Information supplied in the AQAA stated that “Staff have received training in the Surrey Multi Agency procedures - Protecting Vulnerable Adults”. This could not be confirmed at the inspection visit however. Of eight staff training files seen, only two contained a reference to staff undertaking training in safeguarding adults (or POVA), and both of these were three or more years ago. The majority of the residents are not able to manage their own finances independently and may be at risk of financial abuse or exploitation. It is good practice to assess these risks and to record safeguards to minimise the risks. A requirement has been made regarding Standard 23, that arrangement must be made by training staff or by other measures, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home presented as an attractive and comfortable place to live, was well furnished to meet residents’ needs and was maintained to a very high standard of cleanliness. EVIDENCE: A tour of most areas of the home was carried out and it was positive to note the high standards of decoration, furnishing and cleanliness. Communal rooms were spacious, colourful and attractively decorated with co-ordinating furnishings in a homely style. All areas were light and bright and the temperature was maintained at a level which was comfortable for residents. Residents advised that they have keys to their bedroom doors and staff were observed to knock and wait for a response before entering a residents’ room. Residents were keen to show their rooms and spoke of choosing the colours when the rooms were decorated. Each resident’s room has been individually decorated and made personal with their own belongings they advised. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 20 A number of residents require aids and adaptations to enable them to be independent, or to assist staff in the support of residents. These have been provided where required and included hand and grab rails, easy access baths and showers, bed rails, electrically operated beds and hoists. A passenger lift enables residents and staff to access all areas of the home. The high standards of cleanliness and freshness in the home were noted. This is a positive achievement, given the very dependent and complex needs of some of the residents. Liquid soap and paper towels were provided in all appropriate places to maintain hygiene. Staff advised that they are provided with personal protective equipment including gloves and aprons, to prevent infection or the spread of infection. Staff were observed to wash their hands before serving the lunchtime meal. Laundry rooms are provided on both floors of the home, to save staff having to move laundry from floor to floor. These were appropriately equipped with washing and drying machines with the required settings. Staff advised that colour coded cleaning equipment is used in different areas of the home to prevent infection or the spread of infection. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A full team of staff who have been appropriately recruited, are employed to meet the needs of residents. More staff should undertake training to achieve a National Vocational Qualification (NVQ), staff must receive an induction into their role and responsibilities, and staff must receive mandatory training to ensure they can provide skilled and effective support to residents. EVIDENCE: From the information supplied in the AQAA, it was clear that a full team of staff are employed to meet the needs of residents. The majority of the team are care or nursing staff, but residents are also supported by housekeeping staff, a chef and a visiting maintenance person. A recommendation was made following the last inspection, carried out on 20th February 2007, that the policy regarding NVQ training should be reviewed, as a number of staff expressed their wish to undertake this training. The manager stated that the policy has been reviewed and a number of staff have applied to undertake an NVQ, although no care staff have achieved this qualification as yet. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 22 The files of recently recruited staff were sampled and almost all of the required documents and information were present, including Criminal record Bureau (CRB) disclosures and two written references. The references for one member of staff were not held on file, but were supplied to CSCI within one week of the inspection, as these had been held at the head offices of the Surrey and Borders Partnership NHS Trust. It is required that the specified information and documents must be kept in the home, including references. The staff rota was reviewed and shortfalls in the record keeping regarding staff and management working hours were noted. These are referred to at Standard 41, which relates to record keeping. Although most of the residents have a learning disability to varying degrees, no specific induction training has been provided, such as the Learning Disability Awards Framework. This would provide staff with an understanding of the specific needs of people with learning disabilities and how to provide effective support in order to meet those needs. From the three staff files sampled, it was noted that only one had a completed induction record, but this had not been dated to show when it was carried out. For another member of staff, some areas of their induction record had been signed off by the staff member and the manager, although again, none of these were dated. For the third staff member, there was no record of induction at all, although the person had been employed to work in the home for nine months. It is not clear how these staff would know about their role and responsibilities, or be aware of the home’s policies and procedures which they are working to. Staff training records were also sampled and it was noted that many staff have not received mandatory training (which is required by law) for a number of years, so it is not clear how staff would have the skills or knowledge to carry out their roles effectively, or safeguard residents in emergency situations. The records indicated that most staff have not received fire safety training since 2005 or moving and handling training since 2004. Staff had not received first aid or basic life support training since 2004, although some staff had not received this since 2002 or 2003. Food hygiene training certificates usually last for three years, but all those seen in the home had expired, including that of the chef. The manager stated that he had undertaken a food hygiene course entitled “Safer Food, Better Business”, with the local environment health department. When the environment health department was contacted however, they stated that this course is not a food hygiene course, is quite different in content and does not equate to a food hygiene course. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 23 Two requirements have been made regarding Standard 35, firstly that staff must receive induction training and a record of the induction must be maintained and kept in the home and secondly, that staff must receive mandatory and other training which is appropriate to their role. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there are some excellent and good outcomes for residents, other aspects, including residents’ contracts, safeguarding residents, staff training and quality assurance need to be managed more robustly. This is to ensure residents are aware of the terms and conditions they live under, are supported by a skilled and knowledgeable staff team and can be sure that the home is run in their best interests. EVIDENCE: The manager stated in the AQAA that he is a qualified nurse with twenty years experience in the provision and management of care. The manager advised that he had started to undertake the NVQ Registered Manager’s Award, but has yet to complete this. A deputy manager, who is also a qualified nurse, provides support to the manager, he advised. During discussion, the manager advised that he works in a supernumerary capacity for three days each week, Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 25 in order to carry out the management role, although these days are not specified on the staff rota. The staff rota was reviewed and it was noted that it did not include ancilliary staff, so it was not clear what hours these staff work. It was advised that the chef does not work on Sundays, but there was no record of the specific hours worked by the chef. It was advised that the manager does the cooking on Sundays, although there was no record on the rota, of the manager being on duty on Sundays. It was also noted from the review of the rota, that the manager is allocated to work two consecutive, waking night duties each week, in addition to five other shifts. The rota recorded that on one day each week, the manager worked a morning shift followed later that day by a waking night shift. The practice of working seven days each week, with insufficient rest gaps between shifts, may put the health, safety and welfare of residents, and of the manager at risk, and must be reviewed. The rota must be maintained as an accurate record of the staff on duty in the home and must record whether the hours allocated were actually worked. Information supplied in the AQAA stated that residents have varying communication abilities, and some residents are able to give their views, others need encouragement and other residents are unable to express themselves. The AQAA indicated that there is free communication between residents and staff on a daily basis and through regular contact with the representatives of residents. Staff advised that changes had been made in the home, such as the seating arrangements in the dining rooms, in response to requests by residents. The manager advised that most of the responses to the last quality assurance survey, which was carried out in 2006, were positive, although a summary of the results or an action plan arising from it, were not available. A survey into the quality of the service has not been provided to residents, or others involved in their support during this year the manager stated, but it is planned to supply this in the near future. As the home is run by an organisation, which is not in day-to-day control, visits to the home must be carried out as required by Regulation 26. This regulation requires the organisation to appoint a person to make monthly, unannounced visits to the home. The visitor should speak to residents and staff, look around the premises and write a short report of their findings. A copy of the report must be kept in the home. The manager stated that Regulation 26 visits have been carried out, but no copies of the reports were available in the home. The manager agreed to forward the Regulation 26 reports for the last three months, but at the time of Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 26 writing this report, these had not been received, so it is not clear if the visits have been carried out as required. A requirement has been made regarding Standard 37, that the manager’s working hours must be reviewed to ensure the health, safety and welfare of residents and the manager. Further requirements have been made regarding Standard 39, firstly that a review of the quality of the service provided must be carried out in consultation with residents and their representatives and secondly that visits to the home as required by Regulation 26 must be carried out. A requirement has also been made regarding Standard 41, that the rota must be maintained as an accurate record of all people working in the home and whether the rota was actually worked. The equipment and systems in the home including the lift and hoists. have been serviced and maintained to promote and protect the health and safety of all those living and working in the home. Information supplied in the AQAA stated that gas, electrical, and fire safety appliances or equipment have also been tested as required. Fire records were seen and these confirmed that the alarm in the home is tested on a regular basis. Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 27 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 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 4 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 2 X 2 3 x Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 YA5 Regulation 5, 5A & 5B Requirement Each resident must be supplied with a contract or a copy of the statement of the terms and conditions for living at the home. Timescale for action 22/02/08 2 YA23 13 (6) Arrangements must be made, by 22/02/08 training staff or by other measures, to prevent residents being harmed or suffering abuse, or being placed at risk of harm of abuse. Staff must receive induction training and a record of the induction must be maintained and kept in the home. Staff must receive mandatory and other training, which is appropriate to their role. The home must be conducted to promote and make proper provision for the health and welfare of residents. Specifically, the registered manager’s working hours must be reviewed to ensure the health, safety and welfare of residents, and of the manager. DS0000017648.V356260.R01.S.doc 3 YA35 17 Sch. 4 and 18. 05/12/07 4 YA35 18 22/02/08 5 YA37 12 (1) (a) 28/12/07 Throwleigh Lodge Version 5.2 Page 29 6 YA39 24 A survey into the quality of the service provided must be carried out in consultation with residents and their representatives. Visits to the home must be carried out as required by Regulation 26, and copies of the report written must be kept in the home. 22/02/08 7 YA39 26 28/12/08 8 YA41 17 Sch. 4 The staff rota must be 05/12/07 maintained as an accurate record of all persons working in the home and must record whether the rota was actually worked. 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 YA2 Good Practice Recommendations It is recommended that any assessment of the needs of a prospective resident is signed and dated by the person carrying it out. This will ensure it is clear who has carried out the assessment and when. It is recommended that all information relating to residents is kept in their individual plan, as this is more person centred. Where residents are not able to manage their own finances independently and may be at risk of financial abuse or exploitation, it is good practice to assess these risks and to put safeguards in place to minimise the risks. The home’s policy and procedure regarding abuse should be reviewed and revised. Staff in the home should undertake a National Vocational Qualification to level 2 in care, to ensure that at least 50 of the care staff are trained to this level. 2 YA6 3 YA23 4 5 YA23 YA32 Throwleigh Lodge DS0000017648.V356260.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone , Kent ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V356260.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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