Inspection on 16/06/06 for Tamar House

This inspection was carried out on 16th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tamar House 21/01/08

Tamar House 20/12/05

Tamar House 29/06/05

Tamar House 24/11/04

Tamar House 18/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Tamar House 5 Riseholme Road Lincoln Lincs LN1 3SU Lead Inspector Mr Ken Hague Unannounced Inspection 16th June 2006 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 Tamar House DS0000002433.V300282.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. Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tamar House Address 5 Riseholme Road Lincoln Lincs LN1 3SU 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) 01522 524093 Prime Life Limited Mr Shane Haines Care Home 13 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (2) of places Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: The Care Home is an adapted detached two-storey Victorian property situated on the edge of a residential area, in the northern part of the City of Lincoln. A small-secluded garden is situated at the back of the home with an enclosed garden at the front and both can be used by residents. A large extension to the property has provided eight single bedrooms bringing the total provision to twelve. The home offers care services to 13 residents with a learning disability. They are provided with opportunities to access a number of day care facilities within the local area and Prime Life Ltd provides transport. . Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours. The registered manager was present throughout the inspection. The commission received 15 residents’ feedback forms (“have your say documents”) from residents at the care home. This form asked residents 12 questions regarding services provided by the care home. All of these forms were analysed and their contributions are included in this report. Their comments and views are reflected within the inspection report. This information was analysed prior to making a site visit on the 16th of June 2006. Feedback was given at the end of the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of interaction between staff and residents. A sample of care records was inspected. The Inspector explained to the registered manager the changes introduced in the inspection process since April 2006 which included a short presentation using material supplied by the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? The care home continues to provide long-term residential care while taking into account the wishes and choices of residents. It continues to meet all key Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 6 National Minimum Standards. The home has reviewed the security of the care home building. A new alarm system has been installed additional locks added to some doors and glazing upgraded in the front door. 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. Tamar House DS0000002433.V300282.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 Tamar House DS0000002433.V300282.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is Excellent. This judgement has been made using the available evidence including a visit to this service. The home completes a assessments prior to admitting any resident to the care home ensuring that all their needs are identified and the care home has the resources to meet individual resident’s needs. The home does not provide intermediate care services. EVIDENCE: This standard has been met at the last four inspections. The registered manager confirmed in a telephone discussion on the 14th of June that all residents had a full assessment on their individual care file. He confirmed that a new resident admitted since the last inspection had an assessment including a risk assessment on her individual file completed prior to her admission. He confirmed that the home follow the procedures of Prime Life Ltd which states all residents must be provided with a full assessment prior to being admitted. Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 9 A care plan and assessment sent in October 2005 to the Commission for Social Care Inspection demonstrated that a new resident had been assessed prior to coming to stay at the care home. Three residents case tracked during the site visit all had comprehensive assessments on their individual care files. The statement of purpose for the care home states intermediate care is not offered at Tamer House. Tamar House DS0000002433.V300282.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is Excellent. This judgement has been made using the available evidence including a visit to this service. Care plans contain comprehensive information, which identify the care needs and personal preferences of the residents. Risk assessments are of a good quality, providing management strategies that enable residents to be as independent as possible EVIDENCE: The registered manager stated that all “residents care plans include their identified health, personal and social care needs. Chiropody, dental checks and eye care are arranged for all residents, Staff assist residents to keep hospital and doctor appointments.” The case tracking process and inspection of resident’s individual file confirmed this statement to be correct. The fifteen “have your say” documents completed by residents provided evidence that residents feel they received the care and support they need and that their health care needs are being met. Staff interviewed stated that they had received training in the administration and storage of medication, training Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 11 records supported this statement. The pharmacist has visited the home since the last inspection they inspected medication records and checked stock levels. There were no recommendations made to the home at the conclusion of the visit. Residents stated during discussions that staff respect our privacy and dignity. This view was again reflected in the “have your say” document. A care plan for a resident been case tracked provided evidence that identified risk have been balanced against the residents choices and wishes when considering them going into the community unsupervised. Tamar House DS0000002433.V300282.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 at least once during a 12 month period. 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 the available evidence including a visit to this service. Residents are encouraged to keep in contact with their family and friends. All visitors are made welcome by staff at the care home. Catering arrangements for the home reflects the residents choices, preferences and personal dietary needs. Residents with a special diet are provided with a menu which takes their personal needs into account. EVIDENCE: The pre-inspection questionnaire sets out a number of activities offered to residents. Residents confirmed in the “have your say” document that activities are organised which meet their individual needs. The registered manager confirmed that two residents are enabled to attend their choice of church with their family. Discussions held with residents, staff and the registered manager provided evidence that residents are encouraged to maintain contact with their own families. The families are invited to social events at the care home and regular home visits are arranged for residents. One resident stated that he had taken a holiday recently with his family. The registered manager stated that “all residents staying in the care home are provided with an annual Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 13 holiday”. Care plans contained the choices and wishes of residents in respect of the manner in which individual care should be provided and their own individual choice of activities. The pre- inspection questionnaire contained a detailed menu which provided evidence of choice of diet being offered to all residents. Resident stated in the “have your say document” that they were happy with the food being provided by the care home. One resident stated “I would give nine out of 10 for meals staff help me choose meals and maintain a healthy diet” Tamar House DS0000002433.V300282.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Excellent. This judgement has been made using the available evidence including a visit to this service. The home listens to resident’s views and wishes and acts on them. They are procedures in place to protect residents from any possible abuse. Staff have received appropriate training to protect residents from being harmed. EVIDENCE: The “have your say documents provided evidence that staff listen to residents and that residents are able to raise any concerns with a member of staff. There has been an adult protection inquiry held since the last inspection which demonstrated that the staff acted appropriately when a resident made an allegation. This allegation was found to be unfounded. The registered manager stated that no complaint has been received by the home since the last inspection. The Commission for Social Care Inspection has received no complaints in the last year. The registered manager confirmed on the 14th of June that all staff had been trained in the prevention and recognition of abuse. The pre- inspection questionnaire contains a training plan, which supports this statement. Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. 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 the available evidence including a visit to this service. Residents live in a well maintained clean environment . Staff are following the infection control policy of the care home. EVIDENCE: Residents have stated at each inspection held in the last four years that they are happy with the environment and care home. The “have your say” documents supplied for this inspection confirmed that residents are still satisfied with environment of the care home which they state to be always fresh and clean. The registered manager confirmed in a discussion on the 14th of June 2006 that ongoing maintenance is still being carried out in the care home. He gave examples of work carried out to improve the security of the care home. This includes the replacement of a front door window with a secure strengthened glazing. The introduction of a alarm system within the care home. Additional locks fitted to the kitchen to improve the security the care Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 16 home. He stated maintenance staff are carrying out ongoing maintenance. The Registered manager confirmed that safety checks are being carried out on all fire equipment, staff have been trained in fire evacuation and fire alarms are being checked weekly. The registered manager stated that there are no health and safety issues identified at the care home. He said the home is a safe environment for my staff to work in and for residents to live in. Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. 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 the available evidence including a visit to this service. The home is staffed with appropriate numbers of care staff who are sufficiently trained to be able to answer the needs of residents who fit within the registration category of the care home. The managers of the care home are following the home’s recruitment policy consistently. Staff supervision is being carried out in accordance with the National Minimum Standards. EVIDENCE: Staff have received appropriate training to be able to meet the identified needs of the residents who were being case tracked. Evidence for this statement was found in the staff training Plan. The registered manager stated that staffing levels are reviewed as the occupancy changes to ensure residents needs can be met. The care staff interviewed stated that they were able to meet the needs of the residents with present staffing levels. Residents stated they felt that there was sufficient staff on duty to meet their needs. The recruitment policy of the care homes has been followed. The Inspector looked at one personal files for a new member of staff. This provided evidence that the recruitment policy of the care home is being followed all appropriate information required under the Care Home Regulations had been obtained prior to employment being offered. The new member of staff had been provided with an induction. Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 18 Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 312,33,35 &38 Quality in this outcome area is Excellent. This judgement has been made using the available evidence including a visit to this service. The home has an experienced registered manager in post, who ensures that the National Minimum Standards are met and is very supportive to all staff The residents feel that the home is run in their best interest. Financial records and procedures are in place to safeguard the financial interest of residents. Staff are receiving supervision in accordance with the National Minimum Standards. New staff are provided with an induction. EVIDENCE: The home has an experience registered manager in post who holds the registered manager award. Staff state that he is very supportive and approachable. The “have your say” documents completed by residents provide Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 20 support to the inspectors judgement that the home is run in the best interest of residents. The inspection of care records demonstrated that the policy and procedures of Prime Life Ltd are being following in respect of the management of resident’s finances. The registered manager confirmed that these records are audited by senior member of management as part of the prime life Ltd policy. There were no health and safety issues identified Jonas inspection. The registered manager confirmed that staff home are following the infection control policy of the care home. Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 21 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 N/a HEALTH AND PERSONAL CARE Standard No Score 7 4 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 4 17 X 18 4 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 4 X 3 X 3 X x 3 Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? 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 Tamar House DS0000002433.V300282.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 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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