Inspection on 11/07/07 for Thomas Owen House

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Thomas Owen House 31/08/06

Thomas Owen House 01/12/05

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 Helen Battle Key Unannounced Inspection 11th July 2007 09:20 Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 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.V343295.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 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.V343295.R01.S.doc Version 5.2 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 nurses@thomasowenhouse.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) Thomas Owen Care Limited Ms Eileen Fitzsimons Care Home 39 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (39), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (39) Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Eight 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 Three named service users over the age of 65 - MD(E) category Date of last inspection 31st August 2006 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 people 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. 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. The Provider informed the Commission for Social Care Inspection on 11 July 2007 that the fees range from £400.00 to £1,400 per week. There are additional charges for hairdressing, newspapers, magazines, chiropody and toiletries. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection a visit to the home took place. The inspector, Helen Battle, visited the home unannounced from 09.20hrs to 15.30hrs. Whilst at the home, key documents such as care assessments, care plans, daily records and the staff records were looked at, and so were the rooms and garden. Seven members of staff were spoken with, along with the registered manager. Three people living at the home were spoken with. One relative was spoken with. The manager had been asked to complete a questionnaire with information about the service, the people who live at Thomas Owen House, and the staff working at the home. This was returned to the Commission prior to the visit taking place. Surveys were sent to five people living at the home, their families and GPs. Two surveys were returned from relatives. These were generally positive. Comments included: “The care home staff are very caring and helpful.” “We are very happy with our relative’s care at Thomas Owen House.” “Good hygiene routine.” “I think my relative receives as good a care as is necessary, maybe a little TLC would make their stay a bit happier.” What the service does well: What has improved since the last inspection? The checks made on prospective staff have been improved since the last visit. The overall appearance and decoration of the home has improved. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 6 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. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 7 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.V343295.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People are properly assessed before moving into the home with the assurance that their needs will be met. EVIDENCE: A comprehensive Statement of Purpose and Service User Guide is available for prospective service users. Detailed assessments are carried out by senior members of staff working at the home prior to agreement that individual needs can be met by the home. Examples of pre-admission assessments were seen for three people living in the home. There was evidence in documentation for people that pre-admission visits had taken place. One relative confirmed that they had been able to visit the home prior to their relative moving there. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. Plans of care are in place but not all reflect the current needs of the people living in the home. People make decisions about their lives and take risks as part of a more independent lifestyle where possible. EVIDENCE: The care plans of three people living at the home were examined. These were generally well detailed and did reflect the current needs of the individuals. However, one of the care plans did not accurately reflect the needs and risk assessment regarding the prevention of pressure ulcers and could potentially put the person at risk of developing ulcers. Some of the documents looked at had not always been dated and signed, so it was impossible to ascertain when a change had been made and by whom. Entries in the daily records have generally improved since the last visit to the home. Records were descriptive of behaviour patterns and of any intervention used and whether the intervention was successful or not. This is good practice. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 10 Three people living at the home were spoken to at length and generally were satisfied with the care and support provided. All three stated that the staff are very good to them and that they are kind and patient. One visitor stated that they were extremely happy with the care and support provided for their relative. The support received by staff at the home to enable people to make choices and take risks was reported by a visitor to be excellent. This was also evident on the day of the visit in observing staff interaction and activities with people living in the home. Risk assessments and care plans were in place related to challenging behaviour. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People living in the home take part in appropriate activities and are part of the local community. Appropriate relationships are maintained. Peoples’ rights and responsibilities are respected. Meals provided at the home are of a good standard. EVIDENCE: People living at the home take part in a variety of activities and attend day centres suitable for their needs. These include a day centre in Batley, going out to do their own shopping, going to local restaurants and going out on trips to such as Cleethorpes, Haworth, Bradford and Yeadon’s. One person is supported to attend a local gym, and another person is supported to maintain a close relationship with their mother who lives in another local care home. A person who likes to spend time outside is supported in this by the staff. The gardens are easily and freely accessed by service users. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 12 People living in the home are supported to go to local hairdressers, GPs, optician and chiropody appointments. The local library is also accessed by people living in the home. There are two full time activity assistants dedicated to supporting people with their daily activities and there is a dedicated vehicle for this purpose. People are able to have their own phone line fitted if wanted and have their own computer, evidence was seen of this. There is also a computer available in the dining room for anyone to access. People were seen to be treated with respect and their privacy and dignity maintained by staff during this visit. People living in the home are supported to maintain links and relationships with friends and family where possible. People spoken to stated that they are allowed to see visitors at any time and the home has evidently worked hard with people to support them with maintaining relationships. The meals provision at the home continues to be of a good standard. Feedback from people living in the home and visitors was very positive and the meal served on the day of the visit was of good. There was a choice of main meal and the inspector was invited to sit with people living at the home and sample the meal of southern fried chicken, chips, and fresh vegetables. This was followed by home-made trifle. Staff were seen to assist people who needed help to eat their meal in a discreet manner, promoting independence where possible. The meal time was relaxed and unhurried with people evidently enjoying their meal. The staff should be commended on the quality of meals and the presentation at mealtimes. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People receive support in a way they prefer and require with their emotional and health needs being met. People living in the home are protected by the home’s policy and procedure for dealing with medication. EVIDENCE: People spoken to stated that the staff are kind and provide personal assistance in a discreet manner which promotes privacy and dignity. People living in the home stated that they are able to choose what times they get up and go to bed. It was evident that people choose their own clothes, hairstyles and makeup. A member of staff was painting someone’s nails during the visit. Another person living in the home asked a member of staff to help her sort out some new clothes she had bought. There was evidence in peoples’ records that support is also provided from specialist nurses and psychiatric support from the hospital. The medication of three people was checked and generally were found to tally with the records held. Where medication is prescribed on an as required basis, staff must ensure that they record how many tablets are given i.e. one or two tablets, to ensure that the actual dose given is recorded. An issue was raised Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 14 regarding one amount of medication which was out of stock. This was found to be a prescribing error in that the amount of medication dispensed was not enough to cover the dose for a month. Staff agreed to follow this up with the person’s GP for a second time in order to try and rectify the problem. Procedures are in place to safeguard people living in the home regarding medication. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. Generally, people feel their views are listened to and acted on. People are protected from abuse, neglect and self-harm. EVIDENCE: People- spoken to felt that they could speak to any member of staff and that they would be listened to. There has been one formal complaint made to the home since the last inspection. This was dealt with appropriately and the correct procedure followed. Written records of the investigation and outcome letters to the complainant are held at the home. The complaints procedure is displayed in the home. Safeguarding (Adult Protection) training has been given to all staff, however this has not been given in a set training session and has not been recorded. Staff spoken to during the visit demonstrated a good understanding of safeguarding (adult protection) issues and procedures. The manager agreed that all staff would have this training formalised within the four months following this visit. The personal monies of three people were checked and were found to reconcile with the records held. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. Generally, the people live in a comfortable and safe environment. The home is generally clean and hygienic. EVIDENCE: A sample of peoples’ rooms were seen to be personalised according to the personal taste of individuals. All the rooms seen were decorated in to a satisfactory standard. Since the last visit, the communal rooms and hallways have been redecorated, as have a number of bedrooms. Plans are in place to develop the service by building new offices and laundry and a small number of ensuite bedrooms to reduce the number of double rooms and provide single accommodation only. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 17 Plans are also in place to refurbish the hairdressing room to make this a more pleasant area for people to spend time in. A designated smoking room has now been identified in line with new smoking legislation. Although there are three extractor fans in this area, the room is still not adequately ventilated. This was highlighted to the manager at the time of the visit who said that she was looking to having another extractor fan fitted. One person living in the home prefers to have their bedroom door left open. This was being done by holding the door open with a chair. This is not safe practice as the bedroom door is a fire door and therefore should have a door guard fitted which will ensure the door automatically closes when the fire alarm is activated. The home was generally clean and odour free. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People are supported by competent and qualified staff, and are protected by the home’s recruitment practices. Staff are receiving mandatory training within recommended timescales. EVIDENCE: All the staff working at the home have received movement and handling training within the last 18 months. The next planned phase of this refresher training needs to be implemented to ensure that staff are kept up to date and practice safe moving and handling techniques. As stated earlier in this report adult protection training needs to be formalised and adequate records held of all staff training. NVQ training is also continuing at the home with 43 of care staff having achieved NVQ level 2 and a further 14 are working towards this. Seven members of staff have completed health and safety training. It was reported from staff and the manager that handover times are used as an opportunity to discuss policies and procedures, inform staff about training and provide discussion about the management of particular people and changes to care plans. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 19 Other planned training includes challenging behaviour, dementia care and mouth care. The recruitment process at the home has been improved since the last visit and now protects the people living there. The records for three members of staff were examined. Two of the records were complete, however only one reference was in place for one of the staff members. There must be two written references taken up prior to staff commencing work at the home to ensure that staff are suitable for the post, and in order to protect people living in the home. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People benefit from a well run home. Peoples’ views underpin development at the home. The health, safety and welfare of people are protected. EVIDENCE: The manager of the home has many years of experience in looking after people with mental health problems. She is currently working towards the NVQ level 4 award in care management. Peoples’ views are listened to and underpin any development of the home’s policies and practices. This has been particularly apparent in improving the meals provision and in providing activities. Monthly management visits are carried out and the provider consults with the people living in the home. Plans are in place to formalise the quality assurance carried out in the home. Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 21 There were no apparent health and safety issues observed during this visit. Weekly tests of the emergency lighting and fire alarm systems are recorded. All staff have received a fire safety update in December 2006. Refresher training in fire safety is now due and all staff should complete this within a month of this visit. Thomas Owen House DS0000001098.V343295.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 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 23 NO 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. 1. 2. 3. 4. Refer to Standard YA6 YA20 YA23 YA24 Good Practice Recommendations Care plans should reflect the current needs of the people living at the home. Accurate records of medication should be maintained. Safeguarding training should be formulised. The hairdressing room should be refurbished. A door guard should be fitted to the identified bedroom door. Further measures should be implemented to ensure that ventilation in the smoking room is adequate. Quality assurance should be formalised as planned. Fire safety refresher training should be given to all staff within a month of this visit. 5. 6. YA39 YA42 Thomas Owen House DS0000001098.V343295.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Thomas Owen House DS0000001098.V343295.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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