A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? The summary describes what people using the service and the staff told us, what we observed and the records we looked at. We looked at the care records of five people, spoke with ten people, family members and three members of staff. Below is a summary of what we found.
Is the service safe?
Assessments were carried out by the staff of people who used the service and care plans written. We reviewed the care plans of five people and saw these represented the needs of the person and ensured that people's needs were identified and met. People were supported to take their medicines in a safe way.
Procedures and audits were not in place to assess and monitor that the service was prioritising people's safety. Legionella water testing was conducted in December 2013 and several areas were non-compliant and of high risk, including dirty shower heads and taps and no screen cover on the water tank. The action plan stated that some actions had already been taken, such as the shower heads and taps were now regularly cleaned but that other areas needing action would not be complete until 28th May 2014. This meant that people who used the service were still at risk five months after the Legionella inspection because prompt action had not been taken by the provider to rectify the problems.
The home had been inspected by the London Fire and Emergency Planning Authority in June 2013 and found to be non-compliant in four areas of fire safety. A follow up inspection was held in April 2014, the report showed that the premises were a medium risk in three areas; fire alarms zones were not adequately identified, fire doors did not have an effective self-closing system and the wooden fire exit stairs from the first floor was a slip hazard. This meant that people who used the service were still at risk because prompt action had not been taken by the provider to rectify the problems.
Staff had not undertaken recent training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards but understood how this could impact on the people they cared for.
Is the service effective?
People received effective care from staff that were trained and supported by the acting manager. Staff received appropriate professional development. Members of the staff team we spoke with told us they felt they had received all the training and information they needed to effectively carry out their roles and responsibilities.
On the day of our visit we saw that people could move freely around the home and the doors to the garden were open. We saw that people passed through the office to their bedrooms or the bathroom and could sit and talk to staff.
Is the service caring?
The service was good and caring. This was confirmed by our observations of the interaction between staff and people. Staff respected peoples' privacy, dignity and their right to be involved in decisions and make choices about their care and treatment. Care plans we viewed detailed people's individual preferences, so that staff knew people's individual wishes.
Some of the people who used the service had complex needs and were not able to fully answer our questions but were happy to talk with us and tell us about their lives, past and present. Most people we spoke with commented positively about the home and staff. People said, 'this place makes me feel good about myself' and 'my room is small but it's ok'. People also said, 'you are treated like family' and 'I get plenty to drink'. We saw that staff treated people with kindness.
Is the service responsive?
People's needs were reassessed on a regular basis and we saw the service responded to any changing needs. People had access to other services and to professionals who worked with the provider and staff for the benefit of people who used the service.
We saw that staff interacted with people and encouraged them to play games but that staff's time could be limited because of the other duties they had. On our second visit we saw that there was one senior care worker and two care workers working. They were preparing, serving and clearing away the evening meal and helping people to have their meal or give personal care. During our second visit, we saw that some people who used the service had to wait for assistance from staff to access the dining room or for personal care. We saw that having to wait for assistance was causing some people distress.
Is the service well-led?
The home employed an acting manager who knew their staff and people well. They were undertaking appropriate management training. In the interim period an application had been received by CQC to register another person as the manager, until the acting managers training was completed.
The acting manager sent surveys to people who used the service and their relatives and representatives. This gave people the opportunity to comment on the care and support provided at Thetford Lodge. We saw that the most recent survey completed in January 2014 contained positive comments about the standards of care provided. These included, 'staff are mostly welcoming and friendly' and 'a professional approach to caring' and 'my (relative) is happy'.
The acting manager told us that Thetford Lodge conducted several audits. Audits were conducted daily, weekly and monthly and included safety of the stairs, carpet edges, lighting, chemical storage and the stair lift. We saw that these audits were not always completed or up to date. We saw that the manager's monthly audits for medication were up to date.