Care Home: Theobald House

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What the care home does well Residents, relatives and staff describe Theobald House as being like part of a family. One person living at the home said `All the staff are like family to me and I could not receive better care`. The relatives we spoke to during our visit commented on the family feel when they visited and the familiarity residents and their guests feel towards each other. A relative told us `this home is home from home and has a nice feel about it and is a very restful place`. Two other people said that Theobald House had given their relative `a safe, happy and enjoyable environment in their old age` and `Theobald House is a loving caringhome in which my relative feels part of a family. They could not have better care and are extremely happy there`. People in the home expressed a high level of satisfaction with the care and support they receive. One person said ` I am very happy and well cared for at Theobald House`. A relative told us that `since this is a small home the staff are able to keep their attention on the needs of the individual`. People receive good support from local doctors and community nurses. People enjoy the freshly cooked meals and home made cakes they are served. The stability of the staff team and the number of residents who have been in the home for some time helps provide a very friendly and informal environment where care is given in accordance with the preference of service users and in a way that pays due attention to service users` rights and dignity. A relative told us `the care home and staff are very helpful at all times and give a very caring service. I even think they go the extra mile`. The home`s physical environment is homely and comfortable, with service users` rooms reflecting their individual tastes and interests. We have not received any complaints or concerns about this service between our inspections. What has improved since the last inspection? To support the individual care provide by the experienced staff a person centred approach to recording how people wish to be looked after and spend their time is being developed. This will provide clearer information about people`s involvement in planning their care. Systems for ensuring staff receive the regular supervision and training they need to provide support and encourage their personal development have been introduced and training updates provided. What the care home could do better: Mr Phillips has identified work that needs to be done to re-establish some of the organisational policies and procedures and direction, of the home. This includes recruiting and registering a new manager. Information about the home provided to people looking for a place and new residents needs to be updated so people have the information they need to make an informed choice that meets the legal requirements for care home providers.To make sure everyone living or working in the building are protected the health & safety policy and procedures need to be reviewed so there are clear and accessible risk assessments, covering all aspects of the service, that meet current health & safety legislation. We have asked the proprietor to take advice from the local fire safety officer, regarding the need to display hazard notices in areas where oxygen is stored or in use. The home does not currently have a lift and this may have an effect on the choice and availability of rooms for current and future residents who are unable to manage the stairs. CARE HOMES FOR OLDER PEOPLE Theobald House 75 Theobald Street Borehamwood Hertfordshire WD6 4SL Lead Inspector Sheila Knopp Unannounced Inspection 17 December 2008 09:25 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 Theobald House DS0000019593.V373514.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 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. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Theobald House Address 75 Theobald Street Borehamwood Hertfordshire WD6 4SL 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) 0208 953 1798 0208 953 0986 karl@peaceknoll.co.uk Peaceknoll Limited Manager post vacant Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2007 Brief Description of the Service: Theobald House is a large detached two-storey property, which has been converted for use as a care home. The home, which is owned by Peaceknoll Ltd., was first registered in March 1985. The original house built in the 1930s has been extended to provided a total of twelve bedrooms, eleven single and one double. Theobald House does not have a lift, which will restrict the choice of rooms available to people with mobility problems who are unable to use the stairs. The ground floor comprises an entrance lobby and hall, a dining room, a lounge, a smaller lounge library room, 5 single bedrooms, the kitchen, the laundry room, a staff room, a storeroom and an assisted bathroom and toilets. Seven bedrooms, 2 bathrooms (one assisted) and the office are located on the first floor. There is a large and easily accessible garden to the rear of the property including a sheltered patio area. There is ample off street parking. The house is within walking distance of local shops, restaurants and pubs, with a local bus service and the railway station close by. Copies of the latest inspection report are available in the home. The information about the home in the form of a Statement of Purpose and Service User Guide need to be reviewed and should be discussed with the manager / proprietor when requesting information. Weekly fees are £480 - £520 per week. Additional charges apply for personal toiletries, newspapers, chiropody, dentistry and hairdressing. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The information in this report is based on a visit to the service by one inspector. For the purposes of this report the Commission will be referred to as ‘we’. During our visit we spoke to the staff on duty (4), residents (7) and their visitors (3). To make sure a wide range of people were able to give us their views about the service provided at Theobald House we sent survey forms to residents, relatives and staff. We received replies from 5 people who live in the home, 5 relatives and 6 staff. We have also looked at the information we have received about Theobald House between our inspections. This included the Annual Quality Assurance Assessment (AQAA) that providers of care services are required to complete each year. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Earlier this year residents and staff experienced the sudden loss of Mrs Maria Phillips, who had 24 years experience as manager and proprietor of Theobald House. It is a testament to Mrs Phillips that the staff have continued to maintain the good standards and individual character of the home, we have reported following previous inspections. Her son, Mr Karl Phillips, has taken over the management of this family run home. Mr Phillips was not present at the time of our visit but has provided further information at our request, to clarify specific areas. What the service does well: Residents, relatives and staff describe Theobald House as being like part of a family. One person living at the home said ‘All the staff are like family to me and I could not receive better care’. The relatives we spoke to during our visit commented on the family feel when they visited and the familiarity residents and their guests feel towards each other. A relative told us ‘this home is home from home and has a nice feel about it and is a very restful place’. Two other people said that Theobald House had given their relative ‘a safe, happy and enjoyable environment in their old age’ and ‘Theobald House is a loving caring Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 6 home in which my relative feels part of a family. They could not have better care and are extremely happy there’. People in the home expressed a high level of satisfaction with the care and support they receive. One person said ‘ I am very happy and well cared for at Theobald House’. A relative told us that ‘since this is a small home the staff are able to keep their attention on the needs of the individual’. People receive good support from local doctors and community nurses. People enjoy the freshly cooked meals and home made cakes they are served. The stability of the staff team and the number of residents who have been in the home for some time helps provide a very friendly and informal environment where care is given in accordance with the preference of service users and in a way that pays due attention to service users’ rights and dignity. A relative told us ‘the care home and staff are very helpful at all times and give a very caring service. I even think they go the extra mile’. The home’s physical environment is homely and comfortable, with service users’ rooms reflecting their individual tastes and interests. We have not received any complaints or concerns about this service between our inspections. What has improved since the last inspection? What they could do better: Mr Phillips has identified work that needs to be done to re-establish some of the organisational policies and procedures and direction, of the home. This includes recruiting and registering a new manager. Information about the home provided to people looking for a place and new residents needs to be updated so people have the information they need to make an informed choice that meets the legal requirements for care home providers. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 7 To make sure everyone living or working in the building are protected the health & safety policy and procedures need to be reviewed so there are clear and accessible risk assessments, covering all aspects of the service, that meet current health & safety legislation. We have asked the proprietor to take advice from the local fire safety officer, regarding the need to display hazard notices in areas where oxygen is stored or in use. The home does not currently have a lift and this may have an effect on the choice and availability of rooms for current and future residents who are unable to manage the stairs. 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. Theobald House DS0000019593.V373514.R01.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 Theobald House DS0000019593.V373514.R01.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): Standard 1 & 3, Standard 6 does not apply to this service People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People tell us they have received the information they need to make their choice of home but we found that the Statement of Purpose and Service User Guide need to be reviewed to make sure they include all the information care home providers are required to make available. People will be involved in an assessment before coming to stay at Theobald House to make sure staff know how they wish to be supported and can meet their individual needs. EVIDENCE: All the residents (100 ) who completed surveys for us said they had received enough information about the home before they moved in so they could decide if it was the right place for them. A number of the current residents spent time on respite stays before joining the home as permanent residents. One person Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 10 told us ‘before moving here I had already spent many happy weeks respite over the last few years so knew this was the right home for me’. Information is obtained from other health & social care professionals who know the person concerned, as part of the pre-admission assessment. Further reviews are carried out within 6 weeks of the person coming to stay; to check if it the right place for them and the care plan put in place meets their needs. Theobald House DS0000019593.V373514.R01.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): Standards 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can be confident that the care they receive will be based on their individual needs and support their dignity. People will be supported to manage their own medicines if they want to and there are safe systems in place for people who need help with this area of their lives. EVIDENCE: Five out of 6 residents (83 ) who completed surveys said they always received the medical support they needed. One person said this was usually the case. All the residents we met during our visit had received support to achieve high levels of personal care. Arrangements are made for them to have their hair done and see opticians, chiropodist and dentists. People are able to retain their own General Practitioner (GP) if they move in from the local area. The records Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 12 we saw confirmed people living in the home receive good support from the local GP and community nursing services. The residents we spoke with were clear that staff know and understand their individual needs. The care they receive is based on based on many years of experience providing an individual service to people that respects their privacy and dignity. Staff are able to provide a consistent and reliable service. They are sensitive to people’s changing physical and emotional needs and able to respond flexibly when changes occur. We looked at the care records of 4 people we had talked with. The information reflected what people had told us about their lives and had been regularly reviewed. Senior staff are currently reviewing the care records to develop a more person centred style of recording to support the care people are receiving. All the relatives we spoke to during out visit and those who completed surveys (100 ) confirmed that they were kept up to date with important issues affecting their relative. One person confirmed they had been involved in a review of their relatives care when things had changed. We could see from the care plan that the record of care had been updated. Another relative told us that ‘the home has a warm, friendly atmosphere and the care given always seems to be client centred. The home seems to have the health and wellbeing of the clients uppermost’. The medication records we saw were completed appropriately. Residents are supported to continue to manage their own medication if they choose to do so. Staff reported attending recent training. Some changes are need to the storage arrangements. The medicines are currently kept in the kitchen, which means they may be affected by changes in temperature and humidity. There have also been changes in legislation that now require residential care homes to provide a specific type of cupboard for the storage of controlled drugs. Guidance has been made available for the acting manager to follow up. No controlled drugs were in use at the time of this visit. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 13 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): Standards 11, 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Theobald House are able to make choices about how they choose to live and are encouraged to maintain their independence and lead stimulating lives. People living at Theobald House enjoy the freshly prepared, home cooked meals they are served. EVIDENCE: In keeping with it’s family style atmosphere the residents look out for each other and spend time in conversation. People knew each other’s life history, favourite pastimes and preferred TV programmes and music. There are views over the garden to look at and a conservatory area filled with plants and books and games to pick up. One resident said she liked reading romances and the library service changed the books regularly. People are also able to reflect their own personality, interests and style by adding personal possessions to their rooms. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 14 All the relatives we spoke to during our visit and those who completed surveys (100 ) confirmed that staff helped residents to keep in touch with them. One person told us ‘as a visitor on a very regular basis I am made to feel very welcome’. Visitors bring a sense of community into the home with them as they engage in the lives of the people they have come to see and join in with other residents. There are also visits from other community groups such as churches and local schools. Staff are able to take people out to the local shops. We have been told that one of the staff is taking a lead on developing activities within the home. The self assessment (AQAA) sent to us states that one of the aims in the next 12 month is to ‘introduce a more extensive and varied program of activities based on individual choice (as well as group activities) i.e. local shopping trips, cinema trips and local library’. This is to be welcomed as an area for further development as there was a less positive response to this area in the surveys we received. Only 1 resident who completed a survey said there were ‘always’ activities they could take part in, 2 people said this was usually the case and 2 people said ‘sometimes’. It was not raised as an issue during our visit where people said they were content. The AQAA also provided information about the introduction of a key worker for each resident and more detailed records of people’s preferences and choices in relation to their diet and personal care. All the residents we spoke to during our visit and who completed survey forms were very positive about the choice of freshly cooked meals they are served. Freshly baked cakes are served with afternoon tea. The soup at lunchtime was also home made. One person told us the meals were ‘cooked to perfection, always very hot, just as you would want, good home cooking’. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 15 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): Standards 16 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at Theobald House can be confident that staff listen to them and take account of their views. People living in the home feel safe because they are supported by staff that they know and respect them as individuals. EVIDENCE: All the people living in the home who completed surveys (100 ) confirmed that staff listen to them and act on what they say. Everyone said they knew how to make a complaint and knew who to speak to if they were not happy. We have not received any complaints or information about this service between our inspections. A new complaints record has been introduced so that a central summary of complaints received and action taken is kept. It was reported that no complaints have been received. The complaint procedure has been updated and includes the address of the Commission. Staff have received updated training in safeguarding vulnerable adults and the Hertfordshire multi-agency safe guarding procedure is available to staff. The care and support provided by staff means people are respected as individuals with rights and they are able to lead dignified lives. Although the staff have worked together for many years they said they felt confident to raise issues and challenge practice where necessary. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 16 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): Standards 19 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Theobald House provides people with a fresh, clean, comfortable home to live in. Planned updating and refurbishment of the public areas of the home will maintain standards. EVIDENCE: Overall Theobald House provides a comfortable, domestic style, well maintained home for people to live in. People are able to personalise their own room with familiar items of furniture, furnishings and personal possessions. However due to the circumstances described in the summary of this report, plans to move ahead with decorating the communal areas and replacing the carpets in the hall, landing and stairway have not moved ahead as quickly as anticipated. We have been advised that quotes have been obtained and work is due to commence. There are also plans to update and refurbish individual bedrooms. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 17 All areas of the home we visited were fresh and clean and people who completed surveys for us confirmed this was always the case. The gardens are well maintained and the proprietor has identified the need to attend to external paintwork in the summer. One person said they were looking forward to spending time with their relative in the garden during the summer. Theobald House does not have a lift. This does not appear to be an issue for the current residents as people with mobility problems have their rooms on the ground floor. Adjustable bath hoist seats are provided to assist people. If moving and handling equipment is needed staff report that the community nurses are able provide individual hoists on request. Staff do not have access to a hoist in the event of an emergency and the proprietor may wish to review this. Staff have been provided with updated training in the prevention of infection. They have access to disposable gloves and aprons and liquid soap dispensers are available in the required areas to promote good hand hygiene. We would advise the organisation to complete the Department of Health ‘Essential Steps’ audit to provide evidence that they meet the infection control standards required of care providers and keep them under review. Residents are provided with freshly laundered bed linen and clothing. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at Theobald House are supported by staff they have known for many years and understand the needs of older people. People can feel confident that recruitment checks will be carried out on new staff to make sure they are suitable to work with vulnerable people. People can feel confident that staff working in the home receive training updates to make sure they continue to have the knowledge and skills required to support changing practices. EVIDENCE: The people who live at Theobald House are supported by a team of staff who have worked in the home for many years and are well known to them. A resident told us ‘all the staff are like family to me and I could not receive better care’. Two senior staff and two care staff were on duty on the day of our visit. Two staff cover the home at night, 1 waking & 1 sleep in duty. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 19 We looked at the recruitment records for 3 of the most recently recruited staff. This showed us that criminal records checks are being carried out and references taken up before staff are employed. All the residents who completed surveys said staff were always available when they needed them. A relative told us that staff were ‘always available to help where needed’. The residents and relatives we spoke with during our visit were all positive about the approach of staff and their relationships with them. All the relatives who completed surveys (100 ) confirmed staff always had the right skills and experience to look after people properly. NVQ training is supported. One of the staff we spoke with is currently studying for an award in care at level 3. We saw evidence that a systematic approach to providing staff with regular supervision and monitoring their performance, development and training had been put in place. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33 & 38. We did not assess standard 35 as people living in the home maintain control over their own finances. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can be confident that suitable arrangements have been put in place to manage the home until a new manager is registered with the Commission. The acting manager and staff have continued to maintain positive outcomes for the people living in the home during difficult circumstances. The acting manager and senior staff recognise the need to review the management systems and focus of the service so that the knowledge and experience held by Mrs Phillips, over her many years as owner / manager, is replaced. EVIDENCE: Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 21 Theobald House does not currently have a manager registered with the Commission and we are aware that Mr Phillips is taking steps to achieve this in the near future. The senior staff member managing the home at the time of our visit came from a sound background in providing care and support to older people and had a clear understanding of the key principles needed to provide positive outcomes for people living in the home. Residents and their relatives have regular contact with key staff and are able to influence the running of the home and the choices they are given through formal and informal processes. People are asked for their views as part of the home’s approach to quality assurance. Questionnaires are sent out annually and we saw the 2007 responses. We advised summarising the findings from the next review and providing feed back to residents and their relatives in the form of a newsletter so they know what the response has been and any action taken. Resident and staff meetings are held. A recent development has been the introduction of ‘next of kin’ meetings. As stated in the summary section of this report there have been changes in key personnel within the organisation that has meant the depth of knowledge they held about systems within the home is no longer available. This means there are areas related to policies and procedures that now need to be reviewed. We are confident, based on the response we have had following our inspection, that action will be taken to address these issues. The proprietors self assessment (AQAA) tells us that there have been improvements in ‘record keeping on training, activities, care plans, reviews and staff supervision’. Residents and their relatives manage their own finances. No personal money is held in the home on behalf of residents. We have advised that an official accident book and individual daily reports sheets are used for each resident, so that information is available and stored in accordance with data protection procedures to protect people’s privacy and provide a continuous record of events for each person. To prevent accidents window restrictors are fitted to windows above ground floor level, radiators in resident bedrooms are covered and hot water supplies are regulated. The hot water we tested was within the required health & safety range to prevent accidents. It was reported that the temperature is currently regulated at the hot water tank but that thermostatic mixer valves are to be fitted at each outlet. We found that a radiator outside a resident’s room had a raised surface temperature that could cause harm if someone fell against it. Immediate action was taken and we have been advised that a flow temperature restrictor has been fitted to reduce surface heat. In discussions with the proprietor we have identified the need for the recorded risk assessments to be reviewed, so there are clear records of the control measures in place to prevent accidents and the checks staff carry out to make Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 22 sure they remain in place. An annual gas safety check is due to take place on 5/1/08. The home had a fire safety inspection on 10/9/07 by the Hertfordshire Fire Safety Service, which confirmed the home met the required standards at that time. We noted that oxygen was being used in one area of the home and have asked the proprietor to confirm with the local fire safety officer what type of sign is required to identify this fire officers in the event of an emergency. We saw copies of the weekly fire safety alarm checks that take place and it has been confirmed that an annual fire safety check of appliances and systems within the home took place on 29/5/08. Training updates for staff in relation to safe working practices are available and they have recently completed courses in moving and handling and fire safety. Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 23 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 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 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 3 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 3 x x x x 2 Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4 5 6 Requirement The home’s Statement of Purpose and Service User Guide must be reviewed and amended as necessary to ensure it is accurate and up to date and meets the requirements of the Care Homes Regulations 2001 as revised. Revised copies must be provided to the Commission and made available to people using the service as detailed in Regulation 6. This is to make sure people have clear and detailed information about the service provided when they are choosing where to live. This requirement was made at the key inspection on 28/2/07 and has been brought forward with revised timescales. The registered person must provide a Controlled Drugs cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. DS0000019593.V373514.R01.S.doc Timescale for action 30/06/09 2. OP9 13(2) 30/06/09 Theobald House Version 5.2 Page 25 This is to comply with a change in legislation that now relates to care homes providing personal care and to make sure that secure storage is available in the event of controlled drugs being prescribed. This was a recommendation from our previous key inspection 28/02/07 and has now been brought forward as a requirement. The registered person must 30/06/09 assess the condition of carpets and decoration in the home’s communal areas and take appropriate action to ensure that they are replaced or redecorated where indicated by that assessment This is to make sure people are living in a well maintained home and that floor surfaces are safe. This requirement has been brought forward from the previous key inspection 28/02/07. A review has taken place and quotes obtained for the work required. The proprietor has advised us that replacement of the carpets in the hallway; stairs and landing will take place before the end of April 2009. Confirmation should be provided on completion of the work. 3. OP19 23(2) Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 26 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 OP9 Good Practice Recommendations Remove the medication storage areas away from the kitchen to provide a more stable environment in terms of changes in humidity and temperature for the medicines. stored in the home. Complete and keep under review the Department of Health ‘Essential Steps’ infection control audit to demonstrate the required standards to prevent the spread of infection are met. Take advice from the local fire safety officer on the need to display an oxygen hazard sign on the door of any room where it is stored or in use. Record the action as part of the home’s fire safety risk assessment. Take advice and review the home’s risk assessments to comply with current health & safety legislation. 2. OP26 3. OP38 4. OP38 Theobald House DS0000019593.V373514.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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