Inspection on 01/12/05 for Thomas Owen House

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thomas Owen House 11/07/07

Thomas Owen House 31/08/06

Thomas Owen House 30/06/05

Thomas Owen House 23/09/04

Thomas Owen House 14/05/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Thomas Owen House Lees House Road Thornhill Lees Dewsbury West Yorkshire WF12 9BP Lead Inspector Jacinta Lockwood Unannounced Inspection 1st December 2005 9.45 Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 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 Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 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 Adults 18-65. 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. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thomas Owen House Address Lees House Road Thornhill Lees Dewsbury West Yorkshire WF12 9BP 01924 458017 01924 488783 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) Thomas Owen Care Limited Ms Eileen Fitzsimons Care Home 39 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (39) of places Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Eleven named service users DE(E) category Services users in MD category who reach age 65 can continue to live in the home providing their needs can still be met One named service user over the age of 65 - MD category Date of last inspection 30th June 2005 Brief Description of the Service: Thomas Owen House care home is a detached, stone built property with enclosed central garden. It provides nursing and personal care for up to 39 service users who are predominantly younger adults with a mental disorder. The registration of the home has changed due to the change in the service provision from older people with dementia type illnesses to younger adults. There are currently 7 older people under the category of elderly dementia, however the home is no longer admitting any new service users in this category. The majority of rooms provide single accommodation, however the home is looking into increasing the provision of single rooms and decreasing the number of shared rooms. None of the rooms have ensuite facilities, and this again is an area being looked into by the registered provider for the future. The home was a former private residence and was converted for care home use in 1989. It is situated in the Thornhill area of Dewsbury and is convenient for local bus services, the church and pub. Shops and the Post Office are within walking distance of the home. The town centre of Dewsbury is a short bus journey away. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out an unannounced inspection of the home on 1 December 2005. The inspection lasted three hours. The focus of the inspection was on requirements and recommendations made following the last inspection in June 2005. The inspectors examined a sample of records and spoke with the provider, manager and two staff members. What the service does well: 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. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed on this occasion. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Service users’ care plans do not fully reflect their needs. EVIDENCE: Standard 6 was assessed and a requirement was made at the last inspection for care plans to accurately reflect the current needs of individual service users. Three care plans were looked at in detail. There was evidence that some care plans are reviewed, but not all risk assessment and care planning documents were being kept under review. And the information within care plans lacked detail. A care plan for a service user with diabetes did not make clear what would be regarded as a ‘sudden abnormality’ which would indicate that the Diabetic Nurse should be contacted. Records showed that the level of glucose concentration varied from 5.2 to 10.1. The manager explained that a service user required feeding by staff but the care plan noted that the service user ‘may need assistance’ to eat. Specific details about oral care and foot care were not included in the care plans. It is important that care plans provide specific instruction and guidance to staff covering all areas of care and support required by service users. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 9 Risk assessments were not available in all cases. For example, there were no risk assessments for service users regarding falls or diabetes. Some records seen were incomplete. And records were not always dated, so it was not possible to assess the currency of the information. Daily records did not always reflect the care plan. For example, one wound care plan noted that the wound should be monitored when the dressing was changed but the condition of the wound was not being recorded on a consistent basis. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed on this occasion. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Service users are not protected by the home’s practice regarding the administration and storage of medication. EVIDENCE: The medication for four service users was checked. The requirement for accurate records of medication to be kept has not been met. Records could not be reconciled with the stock of medication. Medication stock balances were not being brought forward and the stock of some medicines did not tally with the MAR (Medication Administration Record) sheet. It was not clear from the codes being used on the MAR sheet whether medication had been refused, or refused and destroyed. Medication to be used within 28 days of opening did not have the date of opening recorded so it would not be possible to ascertain the date of disposal. One sample of medication was being stored in the fridge when there were clear instructions that, once opened, the medication should not be kept in the fridge. Also, the practice of secondary dispensing of medication was observed. This practice must stop as it places service users at further risk from a poorly operated medication system. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are protected from abuse through the home’s policies and procedures. EVIDENCE: Staff have received training in adult protection and this is also covered in staff supervision. A copy of the home’s policy on adult protection is displayed in the home and each staff member is given a copy of the policy. It is recommended that all staff sign to confirm that they have received, read and understood the policy. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Action is being taken to ensure that the environment provided for service users is homely, comfortable and safe. The home is clean, tidy and free from unpleasant odours. EVIDENCE: The environment is well spaced out with areas for service users to walk around. The garden is well maintained and provides a safe enclosed, accessible area for service users. Redecoration of the environment is ongoing. New windows have been installed throughout the home and a number of new fire doors installed. Extractor fans have been purchased for smoking areas within the home. Maintenance and redecoration works have been carried out to a number of bedrooms and a ground floor toilet, including those areas identified at the time of the last inspection. Plans are in hand to replace the carpet to the large lounge area. This was identified at the time of the last inspection and a recommendation is made. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 14 A limited tour was made of the building and those areas seen were clean and tidy. There were no unpleasant odours. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed on this occasion. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 Outstanding issues and shortfalls mean that the health, safety and welfare of service users is not fully promoted and protected. EVIDENCE: The registered provider, Mr Martin, reported that the fire authority was satisfied that the coffee table and seating on a landing area, identified at the time of the last inspection, did not pose a fire safety hazard. Health and safety records show that tests of the fire system are carried out weekly. Hot water is tested monthly. Some staff received fire safety training in June this year. However, the previous recommendation for all staff, who have not yet done so, to receive fire safety training is carried forward. Generic risk assessments are not available for all safe working practice topics and a recommendation is made. Accident records showed that a service user had been found on the floor on a number of occasions and had sustained an injury on one occasion but a risk assessment had not been completed. Where Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 17 there is an identified risk, a risk assessment should be available and action taken to manage the risk (see Standard 6 above). Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Thomas Owen House Score X X 1 X Standard No 37 38 39 40 41 42 43 Score X X X X X 1 X DS0000001098.V270176.R01.S.doc Version 5.0 Page 19 Yes 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. 1. Standard YA6 Regulation 15 Requirement Care plans must be kept up to date and accurately reflect the current needs of individual service users. (Timescale of 31.07.05 not met). Risk assessments must be undertaken and management of the risk included in the service users’ care plan. Accurate records of medication must be kept. (Timescale of 30.06.05 not met). The secondary dispensing of medication must stop. Medication must be administered from the original container. Staff who have not received fire safety training earlier this year must do so by the end of December 2005. Timescale for action 30/12/05 2. YA6 13(4)(c) 30/12/05 3. 4. YA20 YA20 13 13 30/12/05 30/12/05 5. YA42 23(4) 31/12/05 Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 20 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 2. 3. Refer to Standard YA6 YA23 YA24 Good Practice Recommendations Daily records should reflect delivery of each service user’s plan of care. All staff should sign to confirm that they have received, read and understood the home’s adult protection policy and procedure. The carpet to the large lounge area should be replaced in line with the home’s redecoration plans. Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. Extracts may not be used or reproduced without the express permission of CSCI Thomas Owen House DS0000001098.V270176.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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