Inspection on 30/06/05 for Thomas Owen House

This inspection was carried out on 30th June 2005.

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

Thomas Owen House 11/07/07

Thomas Owen House 31/08/06

Thomas Owen House 01/12/05

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 WF12 9BP Lead Inspector Helen Battle Unannounced 30 June 2005 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 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 Stationary 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 J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Thomas Owen House Address Lees House Road Thornhill Lees Dewsbury WF12 9BP 01924 458017 01924 488783 Telephone number Fax number Email 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 with Nursing 39 Category(ies) of MD - Mental Disorder - 39 registration, with number of places THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 23.09.04 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 J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection at Thomas Owen House on Thursday 30th June 2005, and was conducted by one inspector commencing at 10.30am and finishing at 4.20pm. Eileen Fitzsimons, the manager, and Kevin Martin, the provider, were present at the inspection. The following inspection methods were used in the inspection: sampling of records, care plans, individual discussion with five service users and five members of staff, discussion with the management, tour of the premises and document reading. What the service does well: What has improved since the last inspection? Work has been carried out to improve the environment with the coffee bar area being refurbished to provide a comfortable lounge area for service users. The conservatory area has also been redecorated and a new carpet fitted, with all the chairs in the home having been replaced too. A walk in shower has replaced a bath to improve facilities for service users and increase their independence where possible. The food provision has been reviewed to cater for the needs of the younger client group now living at Thomas Owen House. This has improved the service. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 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. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4. Detailed assessments are carried out for all prospective service users ensuring that staff have a clear understanding of what care should be provided for new service users. EVIDENCE: Detailed pre-admission assessments are undertaken. These are carried out by the proprietor, manager or deputy manager. These include a lot of detailed work around current needs and previous history. The families of prospective service users are involved where possible. Evidence was seen of service users being encouraged to visit the home and spend time there prior to making a decision to live at Thomas Owen House. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9, 10. Service users are supported to make decisions about their lives and are allowed to take risks as part of their chosen lifestyle. Assessed and changing needs of service users are not reflected in their individual plans. EVIDENCE: It is evident that service users are able to make decisions about their lives regarding activities, day centres, meals, contact with families and friends and appearance and healthcare. Service users are also supported to take everyday risks in going out and undertaking activities and independence is encouraged as far as possible. Service users appear confident in staff and information about them is dealt with appropriately. The care plans of three service users were examined. These were not up to date nor did they reflect the current needs of the service users. One of these plans had been dated and signed as being reviewed 3 days before the inspection and clearly did not reflect the very complex needs of one individual. This is not acceptable. Measures must be put in place to ensure that care plans THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 10 are an up to date working document which gives a true plan of how to meet the needs of individual service users. Assessments were also not up to date. Specific details about oral care were not included in care plans. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16, 17. Suitable activities are provided to meet the needs of the individual service users living at Thomas Owen House. Service users are able to be part of the local community. A nutritious healthy diet is provided. EVIDENCE: Evidence was seen of service users attending various day centres and courses, including reflexology. One service user was seen to go out for a GP appointment during this inspection. This was reported to be usual practice, taking service users out to appointments in the home’s vehicle where possible. Other activities include numerous trips out, outings to local parks and film shows. One service user was spending time doing artwork, others were watching television, and a game of dominoes was taking place between service users and a member of staff. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 12 The meals provision at Thomas Owen House has been reviewed to meet the changing needs of the service user group at the home. There is now a more diverse choice in line with service user preferences. The lunchtime meal on the day of the inspection was home made beef burgers or spaghetti Bolognese. Service users spoken to stated that the food provision has improved. Discussion took place with the proprietor and the registered manager regarding the presentation of meals which need to be pureed. Portions of food should be pureed separately and not presented all together in a thick soup form. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20. Service users spoken to indicated that staff are supportive and give assistance as preferred by service users. Medication recording needs to be improved to ensure the safety of service users. EVIDENCE: Detail was included in care plans seen about how individuals prefer to have personal tasks carried out. Physical and emotional health needs are met with support from staff. Staff appeared to have a good understanding of service users’ individual needs, speaking to them in an appropriate manner and giving support in a kind, calm way. Medication records were generally well maintained, however there were some amounts of medication which did not tally with the records. This had occurred where amounts of medication carried forward to the new MAR sheet had not been recorded for medication stored in boxes. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 14 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 standard(s) 22, 23. Service users feel they are listened to. Service users are protected from abuse through the policies and procedures. EVIDENCE: A new adult abuse policy is now in place. This has been developed alongside a new training package for staff since the last inspection. It was reported that all staff will receive this training within the next six months. Protection will increase following staff training. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 15 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 standard(s) 24, 25, 26, 27, 28, 29, 30. Efforts have been increased to improve the environment, however some areas which have a huge amount of wear and tear are not of an acceptable standard. Generally the home is clean and tidy, although some areas were not clean. EVIDENCE: The environment is well spaced out with areas for service users to walk around. The garden is particularly well maintained and provides a safe enclosed, accessible area for service users. A small number of bedrooms have been redecorated since the last inspection and these have been done to a good standard. Two rooms were seen to have specific areas where there was evidence of a leak from the flat roof above. This should be looked into and the decorating made good. One service user bedroom had not been cleaned adequately. Although it was reported that this particular service user chooses not to use their room, it is not acceptable that the room is not cleaned thoroughly. Improvements have been made to the room which previously had a counter/bar in it. This has been removed and the room refurbished to make a THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 16 comfortable, cosy lounge. The conservatory area has also been redecorated and a new carpet fitted. This too is a comfortable, pleasant area to sit in. The main lounge carpet is in need of attention. This carpet was replaced just over 12 months ago but, due to the wear and tear, is badly stained. All the armchairs throughout the home have been replaced since the last inspection. One of the bathrooms has been converted into a shower room. This was reported to be well used by service users and has helped them to maintain their independence. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36. Staffing levels are provided to meet the needs of the service users at Thomas Owen House. Training plans are in place to ensure staff are appropriately trained and updated. EVIDENCE: Staffing levels are in place to meet the needs of service users and meet the staffing levels as agreed with the CSCI. Staff records examined demonstrated that the required checks and references are in place prior to staff commencing employment at the home. Staff spoken to stated that there were good training opportunities at the home. NVQ training continues and staff said that other valuable training courses have been attended including challenging behaviour. Staff confirmed that moving and handling and fire safety training has taken place. The cook is booked to attend a food hygiene course during July 2005. Staff evidently work well as a team and support each other. Staff spoken to confirmed this and gave positive feedback. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 42, 43. The home is generally well managed and run. Service users benefit from the management approach of the home. EVIDENCE: The manager of the home demonstrates competence and ability in managing the home. Service users and staff spoken to stated that the manager is approachable, listens and actions any issues which need addressing. All those spoken to appeared to have confidence in the manager. Service users’ personal monies are kept securely and procedures are in place to safeguard these monies. Work has continued at the home to replace fire doors in line with advice from the West Yorkshire Fire Service. A fire risk assessment for the home has been carried out to ensure the safety of service users. It was observed that comfortable chairs and a coffee table had been placed on a landing area on the first floor. The provider and manager were advised to speak to the West THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 19 Yorkshire Fire Service regarding this to check whether this was appropriate and in line with fire safety advice. Weekly and monthly checks to ensure health and safety are carried out regarding fire alarms, emergency lighting and hot water temperatures. Half the staff team received fire safety training in March and June 2005. The provider was advised that the other half of the staff team need to receive this training by the end of July 2005. A review of generic risk assessments is underway at the home and it was reported that a third of this is completed. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 20 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 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 THOMAS OWEN HOUSE Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 3 J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 21 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 6 Regulation 15 Requirement Care plans must be kept up to date and accurately reflect the current needs of individual service users. Accurate records of medication must be kept. Timescale for action 31.7.05 2. 20 13 30.6.05 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 23 24 30 42 Good Practice Recommendations All staff should receive adult protection training in the next 6 months. Redecoration and carpeting of the identified areas should take place. All areas of the home should be kept clean. Staff who have not received fire safety training earlier this year should do so by the end of July 2005. THOMAS OWEN HOUSE J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 J51J01_S1098_Thomas Owen House_V229222_170605.doc Version 1.30 Page 23 - 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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