Inspection on 31/08/07 for Don Thomson House

This inspection was carried out on 31st August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Don Thomson House 06/09/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

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Bilney Hall

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Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Don Thomson House Low Road Dovercourt Harwich Essex CO12 3TS Lead Inspector Ray Burwood Key Unannounced Inspection 31st August 2007 10:00 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 Don Thomson House DS0000067487.V349974.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. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Don Thomson House Address Low Road Dovercourt Harwich Essex CO12 3TS 01255 240978 01255 506493 louisa.smith@sanctuary-housing.co.uk 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) Sanctuary Care Limited Mrs Louisa Candis Smith Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 28 persons) 6th September 2006 Date of last inspection Brief Description of the Service: Don Thomson House is a purpose built home situated in a residential area of Dovercourt near Harwich, Essex. The home provides residential care for 28 older people, over the age of 65 who may have varying dependency needs. Accommodation is provided through single room occupancy with all rooms except one having en-suite facilities. All areas of the home are accessible, including the gardens through the provision of ramps. There is a passenger lift to the first floor. To the front and side of the home there is ample parking. Current levels of fees charged by the home are between £367:00 and £495:00. Information about the service can be obtained from the home or from Sanctuary Care Head office. New leaflets and booklets about the service are being published to provide more specific information about Sanctuary Care and Don Thomson House, following the purchase of the home from the Shaftesbury Housing Group. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 31st August 2007 with the assistance of the Registered Manager, people who live at the home, staff, and visitors, my thanks to them all. The site visit was conducted between the hours of 10:00am and 3:00pm. The inspection involved a tour of the premises, looking at records, documents, and talking to staff, including the cook and domestic staff. A total of nineteen surveys were received from people living at the home, their relatives and members of the staff team. Feedback and interviews with residents, relatives and staff were positive about the standard of care, support, and the commitment of the management team. A total of 22 standards were inspected with twenty of the standards being met. Two of the standards were partially met. At the end of the site visit, the findings were discussed with the Registered Manager, and advice and guidance given. What the service does well: Don Thompson House provides people who live there with a good standard of care and support, but at the same time allowing them to remain as independent as possible. The home is well managed by someone who is committed to providing residents and relatives with advice and support. Residents’ personal health care needs are well supported by a stable team of experienced and trained care staff. The management and support for staff is good. Training and development opportunities for staff are provided, and ensure that residents’ needs are professionally met. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 6 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. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 7 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 Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 8 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): 1,3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s Statement of Purpose and Residents Guide offers clear information about the home to people wishing to move in. The home’s assessment process is well managed and ensures that prospective residents needs are comprehensively detailed before moving into the home. EVIDENCE: Information contained in the home’s Statement of Purpose and Service Users Guide has been updated to reflect Sanctuary Care’s aims and objectives, together with relevant information about the Registered Provider. Copies of these documents are sent out to people who have applied to move into the home. Since the home’s last inspection visit new pre-assessment documentation has been introduced on a trial basis. The manager explained that the new Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 9 documentation appears to be more directional and easier and quicker to complete. The home’s pre-assessment procedures and records were examined and provided evidence that all areas of need were covered and prospective residents and their families/professionals were involved in the process. The assessment process had recently been updated to include mental health issues. The manager said they liaise with the local National Health Service Matron to residential homes in order to establish a discharge assessment and offer support after admission if appropriate. Some of the people living at the home spoken with said they were able to visit the home, meet other people living at the home and staff prior to making a decision to move in. One comment received by the Commission for Social Care Inspection (CSCI) from survey’s sent out said ‘my niece helped me to look round the home’ and ‘the staff were very helpful’. Additional assessment information was included in files examined that related to Care Management arrangements (Health and Social Services). The home does not offer intermediate care. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 10 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home ensures that the health care needs of residents are identified and met. Medication systems are well managed, promoting the good health and well being of residents. EVIDENCE: The care plans of three people who live at the home were sampled and examined as part of the case tracking process. All plans were seen to be up to date, detailed and contained sufficient information to enable staff to meet the health, personal and social care needs of the individuals they were caring for. Monthly and annuals reviews were up to date. Each care plan contained a monthly monitoring sheet to record individual residents’ goals relating to all aspects of their care, support, and independence. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 11 Residents and one relative spoken with were positive about the care and the respect for privacy and dignity shown by staff. Also, comments received from surveys completed by people who live at the home and relatives said ‘ I am always consulted about care issues and asked my opinion’. The home operates a key-worker system with residents who confirmed that they were able to choose who would carry out their personal care needs. Access to health care professionals such as General Practitioners, Community/District nurses, Opticians, Dentists, hospital services and routine health checks was provided and well documented with records kept of referrals, visits and outcomes. Access to aids and equipment to assist with healthcare needs and disability issues is promoted by the home. The home’s medication policy remains the same as previously reported with systems updated to include information about medication being administered by a named individual, i.e. the Team Leader for each shift, with a second person nominated in case of emergency sickness. Two trolleys are used, one on each floor and appropriate records kept of the administration of medication. Staff spoken with during the lunchtime administration of medicines confirmed that they had a good knowledge of each person’s medication that live at the home and the reasons why they had been prescribed. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 12 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People living at the home experience a varied life at the home with visitors encouraged, various informal activities made available, and good meals. EVIDENCE: The home provides structured activities five mornings per week with the Activities Co-ordinator encouraging residents to become involved in a rage of craft activities. The inspector spent some time with the Activities Co-ordinator who explained that they were in the process of assessing individual residents choices regarding their recreational and social asperations. One resident spoken with said that although the groups were small, everyone enjoyed the different craft activities being introduced. Information about what activities are planned for other than individual preferences, are contained in a “What’s on” programme delivered to each resident. Also, information about special events are listed in the home’s Newsletter. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 13 The Activities Co-ordinator said the home’s programmes information board has been redesigned making it more user friendly and there had been more trips organised for those individuals who wish to go out. Two volunteers have been recruited to assist with activities and trips out. These trips were in addition to individual programmes. The Activities Co-ordinator is the designated driver for vehicles used for trips out and has undertaken the appropriate tests. Visitors spoken with said the home always provides a warm welcome. Other comments received from relatives/visitors in response to surveys said staff always made them welcome and were able to visit family members or friends in private. One person said in the survey received that the home allows individuals to do as they like, if they want something they will arrange it. The manager informed the inspector that they had recently changed food suppliers and would be monitoring the changes to ensure that people living at the home were happy with the quality of meals and snacks. The manager said that this would be achieved through meetings with residents, the chef manager and the domestic supervisor. The home continues to provide good home cooked food including fresh fruit and vegetables, either in a communal dining room, or in to residents rooms if requested. People living at the home are able to invite family to stay for a meal with them should they wish to. One survey received said the home provides food of a high standard, the sort of food elderly people grew up on, not modern day food. Menus examined provided residents with a choice of well-balanced and nutritional meals. A tour of the kitchen area was undertaken and records inspected. The kitchen area was well organised, clean and maintained to a high standard. Residents spoken with during the luncheon period commented on the excellent variety and standard of food cooked. Other residents who had special dietary needs were well supported by staff during meal times. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 14 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 and 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. Arrangements for the protection of residents are good, ensuring that they protected from harm and abuse. EVIDENCE: The home’s complaints policy and procedures were clearly set out and openly available to residents, visitors and staff. The home had received three complaints since the last inspection visit and had followed procedures in relation to timescales and notifying complainants about the outcomes of their investigations. The manager confirmed that the complainants had been notified by letter and were happy with the outcomes. Information regarding the home’s complaints procedures and to whom individuals may wish to consult, including the Commission for Social Care Inspection (CSCI) is contained in the home’s updated Statement of Purpose and User Guide. Adult Protection policies and procedures were in place for staff guidance and available to individuals should they wish to access the information. Staff spoken with confirmed that they had received the appropriate protection training and guidance during their induction period and National Vocational Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 15 Qualification (NVQ) training. Further guidance for staff was available through the Essex Vulnerable Adult Protection Committee information books. Two new members of staff who are currently undertaking their induction programme and at the time of the site visit, have not completed all of their Adult Protection training and are under supervision. There are no current Protection of Vulnerable Adults issues relating to the home. Don Thomson House DS0000067487.V349974.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): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service provides a well-maintained environment that has good facilities, is comfortable and is a generally safe place for those living there. EVIDENCE: A tour of the home provided evidence of work carried out relating to the environment. All areas seen were clean, bright and provided residents with a comfortable environment in which to live. A number of improvements have been made to the environment since the last inspection visit with bathrooms and shower-rooms having been refurbished and redecorated. Some new carpets have been laid in the newly decorated bedrooms. A further programme of redecoration has been planned for remaining areas of the home. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 17 Since the last inspection visit residents safety has been improved through the provision of new grab rails where necessary, to assist residents with getting in and out of bed. Also, pictures of the home’s facilities have been placed on communal doors as well as signage to help people living at the home to get about more easily. A further programme of refurbishment is planned by the home following recommendations made by the Fire Service. New fire doors are to be fitted on the first floor to allow for re-routing during evacuation of the floor. Also, new door handles are to be fitted to the laundry room and new emergency lighting fitted. Don Thomson House DS0000067487.V349974.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): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff in the home are trained, skilled and in employed in sufficient numbers to support and meet the needs of people who use the service. The service operates a robust recruitment process that helps to keep vulnerable people safe. EVIDENCE: Since the home’s last inspection visit two new members of the night waking team have been recruited with appropriate checks being undertaken before they commence their duties. Staffing levels are currently in line with dependency levels based on the Department of Health guidelines contained in ‘Residential Forum’. Sanctuary Care has agreed current staffing hours. Four staff are currently completing their National Vocational Qualification (NVQ) Level 2 which means the home have a ratio of trained staff above the required numbers highlighted in the National Minimum Standards (NMS). The manager has been trained to provide in house training for some safe working practice courses that includes a formal induction based on the ‘Skills for Care’ guidelines. The manager confirmed that staff training is provided for Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 19 at least three days annually and a programme of training is to be implemented for the next year that is consistent with the needs of people living at the home and staff working in the home. Surveys received from staff confirmed that they have the right skills and experience to look after people living at the home and the service meets their different needs. The recruitment files of two members of staff were inspected and found to contain the appropriate checks and personal information required before they commenced employment at the home. Don Thomson House DS0000067487.V349974.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): 31,33.35 and 38. 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. There is leadership; guidance and direction to staff to ensure that people living at the home receive a good quality of care. Residents’ personal wellbeing and safety is well promoted through staff training, comprehensive policies, procedures, and regular health and safety checks. EVIDENCE: Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 21 The home’s registered manager is currently undertaking the National Vocational Qualification (NVQ) Level 4/ Registered Managers Award (RMA) and hopes to complete the qualification soon. However, the manager informed the inspector that they had resigned from the position of manager and would be transferring to an administrative role within the organisation. The post of the manager has been advertised and interviews are imminent. The home’s quality assurance system has been further developed and included a quality assurance and development self audit process that comprehensively covered care documentation; medication practices; individual risk and health related practices. The manager was advised that further development of the system should also include the views of people living at the home, their relatives, staff, and professionals who support the home on a regular basis such as general practitioners, district nurses, other healthcare professionals and social workers. The manager was advised that questionnaires and surveys should be sent out as part of the home’s quality assurance system, the findings analysed, and a report published of the findings. From discussions with the manager and senior staff, residents’ finances are managed effectively with appropriate records kept. Some residents can manage small amounts of cash with others being able manage most of their financial affairs. Records relating to the health and safety of individuals living and working in the home were well maintained with appropriate training undertaken by staff in safe working practices. The testing of equipment and servicing records seen were all up to date. Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 22 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 3 X 3 X X N/A 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 2 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 2 X 3 X X 3 Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23 (4)(a)(b) Requirement Recommendations made by the Fire Service must be implemented as soon as is practicable to ensure the safety of people living and working in the home. An established quality assurance system must be progressed to ensure that the views of residents and other interested parties are surveyed, an analysis of the findings carried out and a report sent to the Commission of Social Care Inspection (CSCI). (Previous timescale of 31/12/06 not met). Timescale for action 30/11/07 2 OP33 24 (1)(2) 31/12/07 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 Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Don Thomson House DS0000067487.V349974.R01.S.doc Version 5.2 Page 25 - 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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