Care Home: Thalassa Nursing Home

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What the care home does well The home is clean and environmentally very pleasant and homely. Detailed records were in place that gave nursing and care staff information that enabled them to provide the help that residents` needed. Residents felt safe and secure and happy that staff could look after them properly and treated them with respect. Relatives expressed the same sentiments on surveys returned. Comments made on surveys were: `I have never had any concerns about my mother`s care`. `The best home in Alverstoke`. `Mum requires a higher level of care which she gets`. `All carers talk to mum when they come into her rooms and always have time for her`. `The home shows concern for residents and the care for residents is very good`. GP comments: ` skilled, friendly individualised care`. `They cared for my elderly relative very well`. `Highly qualified staff`. `Friendly, expert, flexible and homely care`. `This is a caring and competent home`. `The home fulfils its role`. `Full holistic care given`. Staff comments: `Provides a homely atmosphere and good standards of nursing care for clients`. `The service users are given a very high standard of care and all needs are met to the best of our ability`. `The home provides good care for the individual`. The home`s routines were flexible and it promoted the right of residents to make choices for themselves and exercise personal autonomy as far as was reasonably possible, including dealing with their own finances. Residents were pleased with the range of activities provided but the home aspires to providing a more extended activities programme in the near future. Residents were positive about the food that the home provides. Management systems and procedures in the home worked well including quality monitoring and health and safety. Staff were recruited properly ensuring that residents safety and welfare was given proper consideration.There was a strong commitment to staff training and development to ensure that staff were able to fulfil their roles and responsibilities and meet residents needs What has improved since the last inspection? There were no matters of concern identified at the last inspection of the home in October 2006. What the care home could do better: There were no matters of concern identified at this visit to the home. CARE HOMES FOR OLDER PEOPLE Thalassa Nursing Home 79 Western Way Gosport Hants PO12 2NF Lead Inspector Jan Everitt Unannounced Inspection 28th November 2007 09:00 X10015.doc Version 1.40 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 Thalassa Nursing Home DS0000042027.V349542.R02.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thalassa Nursing Home Address 79 Western Way Gosport Hants PO12 2NF 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) 01923 828528 info.thalassa@tiscali.co.uk www.numadahealthcare.co.uk Numada Healthcare Ltd Daphne Serena Coleborn Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (6), Physical disability of places over 65 years of age (33) Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be at least 55 years of age. Date of last inspection 17th October 2006 Brief Description of the Service: Thalassa Nursing Home is a care home providing nursing care for thirty-three residents over the age of 55 years. The home is a large converted and extended house in a residential area of Alverstoke, Gosport and is near local shops and amenities. The accommodation is over two floors, connected by a shaft lift; and consists of twenty-three single and five shared bedrooms and two communal rooms. The home has large grounds, which are accessible to the residents, and there is car parking space to the front and side of the home. Potential residents are invited to visit the home but if they are unable to do so they are sent a detailed brochure/information pack. On admission to the home new residents are given a comprehensive service users guide. A copy of the guide is readily available in the hallway/entrance to the home as is a copy of a report of the last inspection made by the Commission of Social Care Inspection (CSCI) of the home. The fees range from £425 - £650 The fees did not include the cost of hairdressing, chiropody, newspapers and magazines. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site inspection visit to Thalassa Nursing Home, which was unannounced, took place over a one-day period on the 28th November 2007. The manager, Mrs F Clemson was not on duty that day and the deputy manager, Mrs. D Coleborn, assisted the inspector throughout the inspection. The visit to the home formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The manager had returned the Annual Quality Assurance Assessment (AQAA) to the CSCI and the focus of this visit to the home was to support the information stated in this document and other information received by the CSCI since the last fieldwork visit, which was a key inspection in October 2006. Documents and records were examined and staff working practices were observed where possible. The inspector looked around the home and spoke to most of the residents, staff and visiting relatives in order to obtain their perceptions of the service the home provides. Those spoken to were very happy and complimentary about the care and services that the home provides. Surveys had been distributed to service users, relatives, care managers, GP and other visiting professionals. Six service user surveys, eight relative/carer surveys, seven staff and three GPs, one health professional and two care manager surveys were returned to the CSCI. The outcome of the surveys indicated that there was a high level of satisfaction with the service and that generally residents and relatives were pleased with the environment and the care the home provides. At the time of the inspection the home was accommodating 31 residents. A small number of residents were unwell and unable to communicate effectively with the inspector to gain their views of the service. There were no residents from an ethnic group. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 6 What the service does well: The home is clean and environmentally very pleasant and homely. Detailed records were in place that gave nursing and care staff information that enabled them to provide the help that residents’ needed. Residents felt safe and secure and happy that staff could look after them properly and treated them with respect. Relatives expressed the same sentiments on surveys returned. Comments made on surveys were: ‘I have never had any concerns about my mother’s care’. ‘The best home in Alverstoke’. ‘Mum requires a higher level of care which she gets’. ‘All carers talk to mum when they come into her rooms and always have time for her’. ‘The home shows concern for residents and the care for residents is very good’. GP comments: ‘ skilled, friendly individualised care’. ‘They cared for my elderly relative very well’. ‘Highly qualified staff’. ‘Friendly, expert, flexible and homely care’. ‘This is a caring and competent home’. ‘The home fulfils its role’. ‘Full holistic care given’. Staff comments: ‘Provides a homely atmosphere and good standards of nursing care for clients’. ‘The service users are given a very high standard of care and all needs are met to the best of our ability’. ‘The home provides good care for the individual’. The home’s routines were flexible and it promoted the right of residents to make choices for themselves and exercise personal autonomy as far as was reasonably possible, including dealing with their own finances. Residents were pleased with the range of activities provided but the home aspires to providing a more extended activities programme in the near future. Residents were positive about the food that the home provides. Management systems and procedures in the home worked well including quality monitoring and health and safety. Staff were recruited properly ensuring that residents safety and welfare was given proper consideration. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 7 There was a strong commitment to staff training and development to ensure that staff were able to fulfil their roles and responsibilities and meet residents needs What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive assessment of care needs is undertaken by an experienced nurse to ensure that the assistance and support that potential residents need before they move into the home, can be met. EVIDENCE: The home has a newly appointed manager who had been the deputy manager for some time and since her appointment she has reviewed the preassessment document. The pre-assessments were viewed for the sample of four service users that were tracked. The document demonstrated a thorough assessment criteria and covered all aspects of a persons physical and emotional care needs. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 10 The manager or assistant manager, who was the previous registered manager, undertakes all the pre-admission assessments and visits to the potential service users in their homes or clinical areas. The assistant manager said that the care needs assessments from care managers are shared with the home in most cases. Hospital records are always viewed to enable the home to gain an accurate picture of the person’s current condition and to ensure the home can meet their needs. Relatives are involved in this process if they wish to be. The home’s pre-admission assessments are complemented by more thorough and comprehensive assessments of a resident’s needs when they actually move into the home. Potential service users are encouraged to visit the home prior to admission but if they are unable to, relatives usually view the home on their behalf. Information about the home is readily available and the AQAA states that the Statement of Purpose is reviewed six monthly to ensure accurate information is available about the home and this is shared with service users and relatives at the time of enquiry or on their admission to the home. The comments on surveys returned from service users and relatives indicate that they consider they were given sufficient information prior to admission to the home to make informed decisions whether the home could meet their needs. Comments from service user spoken with and surveys, from relatives and care manager were: ‘My husband and daughter looked over the home and obtained all the information as I was in hospital’. ‘’I was given information and am always updated on the information about the home’. ‘If individuals do not have the mental capacity the information about the home is given to their next of kin or representative on their behalf’. ‘My family sorted it out for me and I am happy to be here’. ‘The matron came to see me in hospital before I came here to stay’. ST 6 Intermediate care is not provided in this home. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has systems in place to ensure; the personal and healthcare needs of residents are met; Medication is managed safely and effectively. The home’s ethos and staff working practices ensure that residents’ privacy and dignity is promoted EVIDENCE: A sample of four service user’s care plans was viewed, two of which were the most recently admitted people. The care plans demonstrated detailed assessments, risk assessments, which included a range of potential risks to residents e.g. pressure sores; falls; moving and handling; malnutrition, and plans of how the service user’s needs should be met. i.e. Where a risk had been assessed for poor nutrition, a care plan was written detailing the actions to be taken to manage that risk. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 12 The plans demonstrated regular reviews at least monthly or more frequently, if a service user’s condition or need changed. Daily notes were maintained of actions taken by the staff to provide the needs set out in the plans. It was observed that the care plans had been signed by the service user/representative as evidence of their involvement and agreement with the planned care. Conversation with service users also confirmed that they and their relatives are involved in the assessment and care planning process and also in the review process. The care plans were accessible to the service users and they were maintained in the service user’s own room to enable staff to have information about care readily available and also allowed staff to record their actions or update the plans without delay. Staff spoken with and comments on surveys say that they are well informed in the care plans about the service users and information is also shared at handover meetings. However, one staff comment on the survey was ‘Sometimes some valuable information is missing out of the care plan’. The comments made by service users who were spoken with and from surveys returned by service users, relatives, visiting professionals and staff indicate that there is a high level of satisfaction with the care delivered in the home. ‘Provides a homely atmosphere and a good standard of nursing care for clients’. ‘The home has the necessary equipment to nurse clients safely with equipment like hoists, slide sheets, assisted baths etc.’ ‘I am looked after well but sometimes the assistance I need does not fit in with their schedule’. ‘The home puts the service user’s comfort first’. ‘Equipment necessary is supplied regardless of cost’. ‘Mum requires a high level of nursing care which she receives’. ‘I feel the care home staff look after their residents very well’. ‘Care for the residents is very good and the staff show concern when caring for individual needs. ‘Keep residents’ relatives well informed of the resident’s needs and progress’. ‘The staff are wonderful and nothing is too much trouble’. ‘The home does well caring for my wife’. The records viewed indicated that a range of healthcare professionals visited the home and that arrangements were made for treatment for service users when it was necessary and when necessary attend specialist outpatient clinics were made by the home. One resident commenting the ‘The manager is very good at making medical appointments when necessary’. Residents said that they saw and received treatment from among others, doctors and chiropodist, optician and the dentist. The community psychiatric nurse visits the home six weekly to review those people who have been assessed by that team and being treated by the psychiatrist currently. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 13 The manager said that the home is joint working with the PCT falls coordinator in the prevention of falls and staff have received training on this. The outcome of this is that clients have benefited from this with the provision of preventative medication and equipment to prevent fractures. The home uses the Malnutrition Universal Screening Tool (MUST) to help ensure that the nutritional needs of residents are identified and individuals’ health is monitored routinely and regularly by among other things recording their blood pressure and weight. A survey was returned from the visiting dentist who commented that ‘ A very caring home from a dental viewpoint and staff will actively seek professional advice for their clients’. Surveys returned from service users, relatives and visiting health professionals indicate that they consider that the resident’s health care needs are met and that staff are ‘very good and give holistic care’ ‘‘Highly qualified staff’. ‘Friendly, expert, flexible and homely care’. ‘This is a caring and competent home’. ‘The home fulfils its role’. ‘Full holistic care given’ The home had written policies and procedures concerned with the management and administration of medication. Medication was kept in a locked and secured medicine trolley, cupboards and where required in a medical refrigerator. There was an appropriate storage cupboard/container for controlled drugs should they be required. All medicines were dispensed from their original containers and the only staff that dispensed and were responsible for the management and administration of medication on a day-to-day basis were registered nurses. MAR sheets were viewed and were recorded appropriately. The manager undertakes regular audits of these to ensure they are fully recorded. Good practice noted during the fieldwork visit included: • Recording the temperature of the refrigerator used for storing some medication • Sample copies of the signatures of the Registered General Nurses that dispensed medication • Some sedative medication was treated as if it was a controlled drug Records are maintained of the ordering, receipt, administration and the disposal of medicines and these were accurate and up to date. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 14 The home retains information leaflets about all medicines prescribed for residents. Although health care assistants were not responsible for the management of medication there was evidence that a number had attended courses in medicine management and the home had also arranged for regular reviews of residents medication by the GP. There was evidence from both discussion with staff and an examination of staff training records that all staff working in the home completed induction training that covered the fundamental principles that underpin social care, such as privacy and dignity. Staff were observed to knock on doors before entering a bedroom. The interaction between staff and resident was one of respect and staff were familiar with their preferences. Most residents were accommodated in single rooms and shared rooms are provided with screens that are used to promote privacy and dignity and residents spoken to confirmed that staff working practice ensured that their privacy and dignity is promoted. Comments about this were: ‘Yes they knock on my door before coming in’. ‘They treat me very well and a I feel respected’. ‘If I choose to sit in my room that is ok by the staff’. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home organised a range of social activities that provides stimulation and it also promotes residents self-determination, enabling residents to exercise choice about all aspects of their daily life. Residents were able to maintain links with relatives and representatives. The dietary needs of residents are well catered for with a balanced and varied selection of food available that meets their needs and choices. EVIDENCE: The home employs a part time activities organiser who attends the home three times a week. She has attended training for this role. She arranges a programme of activities and range of social events in order to provide stimulation and interest for residents. A list of the organised activities was on display outside one of the home’s two lounges. The deputy manager said that it is acknowledged that more activities hours are needed and it has been agreed that a number of carers stay on extra hours after their care duties are finished to give one to one support to service users who are unable or choose Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 16 not to leave their rooms. A record of when this takes place was evidenced in the care plans. The activities organiser showed the inspector the records of the activities that take place and who has participated and their level of participation, and whether they chose not to take part. The activities records are held in the main lounge. Social histories are recorded and form part of the assessment and care planning process. On the day of this visit the activities lady was organising a quiz and the service users had thoroughly enjoyed the afternoon. As the afternoon was ending, the lighting went off and the emergency lighting kicked in and the activities organiser was excellent at reassuring the residents and making the incident fun rather than it creating anxiety. The home organises parties and events at festive times of the year and notice board displayed an array of photographs from the previous year’s events. Service users spoken with confirmed that they do have activities some days during the week and were generally satisfied with what is provided. Comments on surveys returned say: ‘We’ve have had some good knees-up parties while being in the home’. ‘Someone visits the nursing home and encourages the residents to participate in activities’. ‘We usually visit in the late morning and there is either music or the TV on. The home hold little events for the residents and the photos are on the wall from the country and western event’. ‘Some-one comes in ¾ days a week and sometimes at weekends and encourages us to participate. Very nice lady’. ‘ Mother has dementia and communication is sometimes difficult’. One relative comment was: More entertainment for people in main lounge, only available three days a week at the moment. A member of staff commented: ‘There is not always enough time to sit with the residents to have one to one discussion or recreation time’. The manager stated in the AQAA that. The home acknowledges that to improve the activities programme more hours must be provided for the activities organiser. The organisation is to review the activities programme as part of the quality assurance work in the next 12 months. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 17 Local clergy visit the home and there are regular services provided for those residents that wish to attend. Entertainers also visit the home periodically to sing the ‘old songs’ with the residents, who said they thoroughly enjoy these occasions. Residents spoken to confirmed that they were able to maintain contact with the families and friends and that there were no restrictions on visiting arrangements. The visitor’s book demonstrated a number of visitors come to the home each day. Service users spoken with said that their families visit regularly and that they sometimes, if they are able, go out with them or visit their homes. Comments on surveys returned to the CSCI indicate that the relatives consider they are made very welcome into the home and that the home is excellent at contacting them to inform them of any changes in their relatives’ condition. The surveys also indicated that the home is good in supporting the residents to maintain contact with their relatives. The home had written policies and procedures about maintaining residents’ confidentiality and also about residents’ rights to access their personal files and case notes. Care plans were observed to be kept in the service user’s rooms and were fully accessible. Staff are aware of the service users rights and the core values of care are introduced to staff at the time of induction. Residents have the choice of bringing personal items into the home, including pieces of furniture, when they move into the home. Whilst walking around the home it was noted that most rooms have been made very individual with resident’s personal belongings and family photographs. It was observed that an inventory of the belongings bought into the home was recorded in the resident’s personal file. The care plans viewed demonstrated that preferences of times people wish to go to bed or get up, where they wish to eat and their food likes and dislikes, was recorded in the care plans. The deputy manager said this information was sometimes gained from relatives at the assessment time. Service users spoken with confirmed that they have choices of how they go about their activities of daily living. One lady saying she preferred to stay in her room in the mornings and come down to lunch, another saying she liked breakfast in her room. At the time of this visit there were a number of residents who were being nursed in bed at all times and unable to advocate for themselves to make choices. These residents looked comfortable and clean and appropriate beds were installed to ensure comfort and skin integrity. Comments from the surveys returned to the CSCI were: Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 18 ‘I feel the service supports the residents in feeling secure and safe and encourage the residents to make their own choices in many aspects of their lives’. ‘Mum is awaiting a downstairs room that she has requested to enable her to look out onto the garden’. ‘I do not believe that the patients I have met are in a position to choose how they live their lives’. ‘Yes they can choose to live the life they choose within limits depending on a person’s circumstances’. A care manager comment was: The home try to cater for individual needs and promote client’s rights and make sure their needs are met’. Residents spoken to were all complimentary about the food provided in the home. The menus and records of food provided indicated that the food was nutritious and there was a wide range of meals provided with a selection of choices every day. In addition special diets and individual preferences and needs were catered for e.g. diabetic and soft or pureed meals. Individuals’ food preferences, dislikes and any food related allergies were recorded in the care plan documents and the details were also readily available in the kitchen. The kitchen was visited and was clean and well organised. The cook on duty was not the regular cook but was aware of service user’s likes and dislikes and was preparing a roast lunch that day. She said that currently the home was not providing any special diets to meet a resident’s cultural or religious needs. The lunch-time meal was observed being served. It was well presented and looked wholesome and service users were very complimentary about the meal. The dinning area is part of the lounge and is not fully used owing to the residents’ choices of remaining in their chairs or in their rooms to take their meals. Residents were able to select the meal that they wanted from a choice made available to them the day before. Comments from residents about the food provided included the following: ‘They ask residents what meals they would like a choice of at least two’. ‘The food is good’. ‘I enjoy the meals and there are choices’. ‘We have a choice of a cooked breakfast if we want one’. Surveys returned to the CSCI indicate that service users usually or always like the meals that are provided for them. The care plans demonstrated that all residents are nutritionally risk assessed and weights are monitored monthly. For those who are identified of being ‘at Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 19 risk’ a care plan is written and food supplements and fortified foods are supplied. The dietician will be involved if the GP considers this necessary. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and residents/relatives can be sure that their complaints are responded to appropriately. Staff have knowledge and understanding of Safeguarding issues, which protects residents from abuse. EVIDENCE: The home has a complaints policy and procedure in place and this is included in the Statement of Purpose and all service users receive a copy of this on their admission to the home. A copy of the procedure is also displayed on the wall in reception area. The home has not received any complaints since the inspection of December 06. The deputy manager produced the complaints log where any complaints are recorded with action outcomes. None were evidenced at this time. Service users spoken with and the indications from the surveys received from service users, relatives and visiting professionals, was that if there were concerns they would go to the deputy manager or manager and have confidence that they would resolve any issues. Comments on surveys were: Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 21 ‘Very few concerns the care is good’ ‘Any concerns I would consult with management’. ‘I would raise concerns with the manager and arrange for this to take place’. The home has a written procedure available for Safeguarding people. The AQAA states that these policies and procedures have been reviewed in the past year. These are intended to provide guidance and ensure as far as reasonably possible that the risk of residents suffering harm is prevented. Staff spoken to said that they received training about protecting vulnerable adults and an examination of staff training records confirmed that staff receive training at induction and a more detailed training six months later and from there on training is mandatory every year. Staff spoken to were also able to demonstrate an awareness of the different types of abuse and the action they would take if they suspected or knew that it had occurred. If, following a risk assessment of an individual’s needs it was considered necessary for that person’s safety to use bed rails, consent for their use is obtained from the individual and/or their representative and consent forms were evidenced in the care plans of having been signed. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment was safe and well maintained. There is an infection control policy and procedures in place and staff practices ensure that as far was reasonably possible residents are protected from the risk of infection. EVIDENCE: The home has a six monthly audit of the environment at which time an action plan is raised for improvements and refurbishments. The manager keeps all maintenance records in the home. The home is well maintained and pleasantly decorated. At the time of this visit the exterior and interior of the premises, its décor, furnishings, fittings Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 23 and equipment were in good repair. The home was clean and there were no offensive odours detected. The home employed maintenance personnel, a gardener and staff dedicated to cleaning. Comments received from service users and relatives on returned surveys indicated that the home is ‘always’ fresh and clean with comments like: ‘I feel the home is a very homely environment and that any improvement could only assist with making it even better’. ‘The home provides a clean and welcoming environment for everyone’. ‘The home is kept very clean’. ‘Whenever I visit the home it is fresh and clean’. The home is in the process of being extended at the rear of the building to provide more en-suite rooms, which will enable the home to reduce the number of double rooms. It will also provide more office space, assisted bathrooms and a hairdressing room. The building works have been established to be unobtrusive as possible, but some of the service users said they quite enjoy watching the men at work. The new building when complete will provide a courtyard garden area for service users to sit. The current laundry is fit for purpose but the new building will provide a new larger kitchen, the present laundry will then be transferred to the old kitchen area to provide a more space for the increase in the number of residents. The home has comprehensive procedures in place concerned with infection control. The home also has the Department of Health (DOH) ‘Essential Steps’ guidance to assess the home’s management of infection control. As a result of this guidance the home has undertaken an infection control audit to identify any weak areas in this area. The report from this audit was shown to the inspector. Written instructions about effective hand washing were on display and alcohol gel hand sanitizers, liquid soap and paper towels dispensers were in all communal WCs. It was observed that protective clothing was readily available and staff were observed using gloves and aprons appropriately. There were sluice disinfectors available on both floors of the home. Effective procedures were in place for the management of soiled laundry items. The AQAA states that all staff have received training in infection control. The training matrix evidenced this and staff spoken to also confirmed their knowledge. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs an appropriate and satisfactory level and skill mix of staff that ensures the needs of residents are met. The home has clear staff recruitment; training and development procedures that ensure the service users are protected and supported. EVIDENCE: The AQAA states that the home employs 33 registered nurses and care staff and 10 ancillary staff., which are Activities organiser, Chefs, Kitchen assistants, Cleaners, Laundry assistant, Maintenance/gardening personnel. In addition to the staff employed to work in the home the company that owned it and three other care homes in the area, provided support through a director of care and training co-ordinators. At the time of this visit the care staff rota setting out the minimum number and skill mix deployed in the home was as follows: Registered Nurses Thalassa Nursing Home 08:00 to 14:00 2 14:00 to 20:00 2 20:00 to 08:00 1 DS0000042027.V349542.R02.S.doc Version 5.2 Page 25 Health Care Assistants Total 5 7 4 6 3 4 In addition to the staff employed to work in the home the company that owns it and three other care homes in the area, provided support through a director of care and training co-ordinators. At the time of this visit there were 31 service users in residence. The overall judgment was that there were sufficient staff on duty to meet the needs of the service users. The deputy manager said that staffing levels are to be reviewed when the new wing is commissioned. Staff spoken to said they were satisfied with the numbers of staff and staff were observed to be taking their time with residents and interacting well with them. Service user spoken to say: ‘The staff are good and they respond to me as soon as they can’. ‘I am looked after well’. ‘Sometimes there are more calls for needs than staff available’. The indicators from the surveys returned to CSCI say that generally the staff are available when the service users need them. The deputy manager said that currently she is trying to obtain more care hours for the morning shift. Comments on surveys returned to CSCI were: ‘I think there are enough staff to meet the individual needs, unless a staff member is sick and we have to wait for a replacement’. ‘They meet the needs of the service users I am sure’. ‘Although the care workers are very nice, cheerful and helpful I feel sometimes there is not enough staff to meet their need’. ‘Staff do meet the needs of my mother’. ‘If staff are unable to cover a shift through sickness we are encouraged to use agency nurses to ensure adequate cover’. Other surveys returned indicated that the service users consider their needs are met. The data information received from the home reports that 56 of care staff have achieved the NVQ level 2 or above qualification. Staff spoken with confirmed they had achieved either NVQ level 2 or 3. A sample of three personnel files were examined, 2 of which were the most recently employed staff members. All statutorily required information and preemployment checks had been obtained and conducted before they had started work in the home. The home does employ a mixed gender and a multi cultural work force. Service users do have choices about the carer’s gender that attend them, and Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 26 these wishes are respected. However, these are not documented as such in care plans. The deputy manager said she would ensure this was recorded in future. All new staff receive a comprehensive induction and health care assistants complete a programme that satisfies the requirements of the training body for the social care workforce i.e. Skills for Care. The induction programme for a carer was viewed and was evidenced to be meeting the standards of the SfC induction programme. The organisation training co-ordinator was able to evidence a training matrix that recorded all training the staff have undertaken in the past year. The home demonstrates that they provide a comprehensive training programme for mandatory health and safety training and other training appertaining to the client group they care for. Training needs are identified at the staff’s yearly appraisal and subsequent supervision sessions. These records were evidenced in the personnel files of staff. Staff comments on surveys were: ‘Each member of staff has yearly appraisals and three monthly supervision sessions’. ‘I undertake training at my own expense to maintain my PREP requirements’. ‘My induction mostly covered what I needed to know to do the job’. ‘My induction covered everything I needed to know to do the job very well’. ‘Up to date training is provided when required’. ‘I have undertaken many courses during my employment with the present owners’ There are always plenty of courses to go on. If there is one you want to go they will try and arrange it’. ‘The service does well and provides in house and outside training’. Indications from the surveys returned to CSCI and talking to staff at the home, suggests that the company that owns the home is committed to ensuring the staff acquire the knowledge and skills needed to meet the complex needs of the residents accommodated and promotes on going staff training and professional development. The AQAA records that the home has agreed in the coming year to an external audit by a Senior Learning Adviser from Skills for Care to ensure best practice is taking place in the home. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s manager and management team provides effective leadership and there are clear lines of accountability. There are systems and procedures in place for monitoring and maintaining the quality of the service provided and promotes the safety and welfare of everyone living and working in the home. EVIDENCE: The current home manager was not present on the day of this visit and the deputy was present. The current manager has been in post since May 06 and has applied to the CSCI for registration. She has been the deputy manager for Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 28 some years and she and the present deputy manager have exchanged roles to enable the deputy to now work fewer hours. The manager is a registered nurse and has achieved her NVQ level 4 in management and the Registered Managers Award. (RMA). Surveys returned to the CSCI indicate that the manager is highly regarded. ‘Any problems I have I feel I can approach the home’s manager who will do her best to resolve the problem’. ‘I have very good support at the home’. ‘The manager is always there to give support’. ‘The manager of the home is very capable and understanding’. ‘The employer of the home is very good and understanding and is concerned for the staff and service users’. Staff spoken to at the time of this visit said they felt very supported by the management team who were always around and approachable. The home has a comprehensive quality assurance system in place. The home and the organisation that own it have implemented systems to monitor the quality of the service that the home provides. These include the use of questionnaire to obtain the views of residents and relatives. Audits of the home’s management systems such as, pre- admission assessments and care plans, management of medication and accident analysis are audited every 2 months. Quarterly house keeping systems are audited quarterly. Responses to questionnaires that were used to obtain the views of the views of residents and relatives were collated and the outcomes were published in the home’s newsletter. The result of the most recent survey was evidenced and demonstrated positive feedback. Responses received were either excellent or good. The home does look after a number of service user’s monies. A sample of the individual monies was examined. The monies are stored in a safe environment and are maintained in individual containers. All records and receipts of transactions are with the monies. Three were examined and one record was found to need updating to reflect a recent transaction. The balances of the other monies were correct and the balances indicated on the records. Records examined demonstrated that the home’s equipment, plant and systems were checked and serviced or implemented at appropriate intervals i.e. passenger lift and hoists; fire alarms, fire safety equipment, portable electrical equipment; etc. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 29 Staff said that they attended regular and compulsory fire and other health and safety training. There was a fire risk assessment for the premises and regular risk assessments of the premises and working practices undertaken. The home’s infection control representative has recently undertaken an infection control audit, which looked at all the potential hazards and risks with regards to infection control, and what could be put in place to prevent or lessen the risks. The results of the audit were presented in a professional manner and identified strategies for the control of infection. The home has a variety of hoists and other equipment in the home that promoted safe working practices. The accident book was viewed and accidents are recorded and reports stored appropriately. The manager undertakes an audit of the accidents records, periodically to identify any emerging themes. Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 31 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 32 Commission for Social Care Inspection South East Regional Contact Team 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 Thalassa Nursing Home DS0000042027.V349542.R02.S.doc Version 5.2 Page 33 - 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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