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Inspection on 31/08/06 for Thomas Owen House

Also see our care home review for Thomas Owen House for more information

This inspection was carried out on 31st August 2006.

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 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service users are supported by a dedicated and competent team of staff. The service users spoken to, and a relative, spoke highly of the staff saying they are kind, caring, pleasant and committed. The home ensures that service users are protected by adult protection policies, medication policies and procedures and the complaints policy. All the service users spoken to said that they knew who to speak to if they were unhappy about anything. Positive interaction was observed between service users and staff. The meals provision at the home is excellent. Service users stated that the food was good and there is lots of choice. Activities are provided to a good standard and to meet the needs of the service users. Two of the three service users spoken to said that there were plenty of activities and the two dedicated activities co-ordinators were spoken about positively.

What has improved since the last inspection?

Nearly all the staff have completed adult protection training. Three bedrooms and the dining area have been decorated since the last inspection. Further new windows have been fitted along with a new front door. New carpets have been fitted to the entrance area and the office refurbished and decorated. Although a new carpet had been fitted to the lounge since the last inspection, this is again looking worn and stained. This is due to the heavy use in this area. An alternative floor covering should be explored.

What the care home could do better:

Daily records need to be more detailed and reflect the care given as directed in the care plan. All health care needs should be documented accurately. Some areas of the home need attention to the decoration. Two specific bedrooms need refurbishing. The recruitment procedures need to be improved in order to protect the service users living at the home.

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 31st August 2006 09:45 Thomas Owen House DS0000001098.V303437.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.V303437.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.V303437.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 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.V303437.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Eight named service users DE(E) category Service 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 1st December 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. 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 15 June 2006 that the fees range from £420.28 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.V303437.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit. The inspector arrived at the home at 9.45am and left at 4.45pm. During this visit the inspector spoke to some of the service users, visiting relatives, some of the staff and the home’s management. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the building. Prior to the inspection, ten service user questionnaires were sent to Thomas Owen House to obtain the views of service users living at the home. Three completed questionnaires were returned. There were thirty two service users living at the home on the day of this inspection. Unfortunately, due to information regarding next of kin, GPs and social workers not being forwarded to the Commission, surveys were not sent to these parties. Other information used as part of the inspection process included notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider, and a pre-inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: The service users are supported by a dedicated and competent team of staff. The service users spoken to, and a relative, spoke highly of the staff saying they are kind, caring, pleasant and committed. The home ensures that service users are protected by adult protection policies, medication policies and procedures and the complaints policy. All the service users spoken to said that they knew who to speak to if they were unhappy about anything. Positive interaction was observed between service users and staff. The meals provision at the home is excellent. Service users stated that the food was good and there is lots of choice. Activities are provided to a good standard and to meet the needs of the service users. Thomas Owen House DS0000001098.V303437.R01.S.doc Version 5.2 Page 6 Two of the three service users spoken to said that there were plenty of activities and the two dedicated activities co-ordinators were spoken about positively. 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.V303437.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.V303437.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4. Service users have information to help them make an informed choice about where to live. Service users have their individual needs assessed prior to admission into the care home. Service users are encouraged to visit the home prior to admission. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. 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 two service users. There was evidence in documentation for service users that pre-admission visits had taken place. One service user stated that they had been invited to visit the home on a number of occasions before admission took place. Thomas Owen House DS0000001098.V303437.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Plans of care are in place but service users do not always see their plan. Service users make decisions about their lives and take risks as part of a more independent lifestyle. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care plans of four service users were examined. These generally did reflect the current needs of the service users. However, two of the care plans had not been adequately reviewed and there was conflicting information in these two care plans regarding the current needs of the service users. There was no evidence of service users being involved in the formulation or review of their care plans. Entries in the daily records varied in detail. A small number of entries were very good and detailed what care and support had been given to individuals on a daily basis. The majority of entries, however, were poor and did not detail any information which indicated what care and support had been delivered. Thomas Owen House DS0000001098.V303437.R01.S.doc Version 5.2 Page 10 Two of the three service users spoken to at length stated that they were happy living at the home. All three stated that the staff are excellent, “couldn’t wish for better” and that they are kind and patient. The support received by staff at the home to enable service users to make choices and take risks were reported to be excellent. This was also evident on the day of the visit in observing staff interaction and activities with service users. Risk assessments and care plans were in place related to challenging behaviour. Thomas Owen House DS0000001098.V303437.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Service users take part in appropriate activities and are part of the local community. Appropriate relationships are maintained. Service users’ rights and responsibilities are respected. Meals provided at the home are excellent. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users 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. One service user stated that they had been to a football match, supported by a member of staff from the home. A service user who likes to spend time outside is supported in this by the staff. The gardens are easily and freely accessed by service users. Service users are supported to go to local hairdressers, GPs, optician and chiropody appointments. The local library is also accessed by service users. Thomas Owen House DS0000001098.V303437.R01.S.doc Version 5.2 Page 12 There are two full time activity assistants dedicated to supporting service users with their daily activities and there is a dedicated vehicle for this purpose. One service user had identified that they would like their own phone line fitted. This had been accessed and, on the day of this visit, a phone was being fitted in the service user’s room. One service user has their own computer and there is also a computer available in the dining room for any service user to access. Service users were seen to treated with respect and their privacy and dignity maintained by staff during this visit. Service users are supported to maintain links and relationships with friends and family where possible. Service users spoken to stated that they are allowed to see visitors at any time and the home has evidently worked hard with service users to support them with maintaining relationships. The meals provision at the home is excellent. Feedback from service users was very positive and the meal served on the day of the visit was of a good standard. This was home-made shepherd’s pie, broccoli, carrots and gravy or home-made fish kebabs with vegetable rice. This was followed by home-made trifle. Staff were seen to assist service users in a discreet manner, promoting independence where possible. The meal time was relaxed and unhurried with service users evidently enjoying their meal. The staff should be commended on the quality of meals and the presentation at mealtimes. Thomas Owen House DS0000001098.V303437.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users receive support in a way they prefer and require. Emotional and health needs are met, however these are not properly documented. Service users are protected by the home’s policy and procedure for dealing with medication. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users spoken to stated that the staff are kind and provide personal assistance in a discreet manner which promotes privacy and dignity. Service users also stated that they are able to choose what times they get up and go to bed. It was evident that service users choose their own clothes, hairstyles and makeup. One service user stated that they had been out clothes shopping on the morning of this visit with the support of a member of staff. There was evidence in the records of service users that support is also provided from specialist nurses and psychiatric support from the hospital. Thomas Owen House DS0000001098.V303437.R01.S.doc Version 5.2 Page 14 The medication of four service users was checked and all were found to tally with the records held. Procedures are in place to safeguard service users regarding medication. Thomas Owen House DS0000001098.V303437.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Generally, service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Two of the three service users spoken to felt that they could speak to any member of staff and that they would be listened to. There have been no formal complaints made to the home or received by the Commission since the last inspection. The complaints procedure is displayed in the home. The majority of staff have received adult protection training since the last inspection. The five remaining staff who have not yet received this training are to undergo this training within a month of this visit. The personal monies of two service users were checked and were found to reconcile with the records held. Thomas Owen House DS0000001098.V303437.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Generally, the service users live in a comfortable and safe environment. The home is generally clean and hygienic. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A sample of service users’ rooms were seen to be personalised according to the personal taste of individuals. Two rooms were in need of decorating and these were identified to the manager at the time of the visit. Since the last visit, new windows have been fitted in parts of the home, a new front door has been fitted, new carpets have been fitted in the entrance area and the lounge, and three bedrooms have been redecorated. There are still many signs of wear and tear throughout the home and, although there are designated maintenance staff, they are also responsible for the maintenance of 2 other homes within the group. Due to the size and age of the home, it is recommended that Thomas Owen House should have a full time designated maintenance person solely to work at this one home. Thomas Owen House DS0000001098.V303437.R01.S.doc Version 5.2 Page 17 Thomas Owen House DS0000001098.V303437.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Service users are supported by competent and qualified staff. Service users are not protected by the home’s recruitment practices. Service users’ needs are met by appropriately trained staff. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: All the day staff but one working at the home have received movement and handling training. The next planned phase of this refresher training is for the night staff and then ancillary staff. Adult protection training is underway and all but 5 staff have completed this. The home is looking into training a senior member of staff as a health and safety facilitator to update the rest of the staff team. NVQ training is also continuing at the home with 25 of care staff having achieved NVQ level 2. Other planned training includes challenging behaviour, dementia care and mouth care. Thomas Owen House DS0000001098.V303437.R01.S.doc Version 5.2 Page 19 The recruitment process at the home is not currently protecting the service users living at the home. The records for four members of staff were examined and none had a completed CRB check in place prior to commencing work at the home. This is not acceptable and could place service users at risk. It was reported that the home have already identified this as an issue and that a new procedure is being introduced to remedy this issue. Thomas Owen House DS0000001098.V303437.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Service users benefit from a well run home. Service users’ views underpin development at the home. The health, safety and welfare of service users are protected. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The manager of the home has many years of experience in looking after this service user group. She is currently working towards the NVQ level 4 award in care management. Service users’ 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 service users. Thomas Owen House DS0000001098.V303437.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. Not all staff have received fire safety update twice a year. This is likely to be a consequence of the workload of the fire trainer who is also one of the maintenance staff. This issue was highlighted earlier in this report. Thomas Owen House DS0000001098.V303437.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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 2 X Thomas Owen House DS0000001098.V303437.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA34 YA42 Regulation 19 23(4) Requirement Staff must not commence work at the care home until a CRB check has been obtained. Staff who have not received fire safety training earlier this year must do so by the end of September 2006. Timescale for action 30/09/06 30/09/06 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 YA19 YA23 Good Practice Recommendations Service users should be involved in the development and review of their care plan. All health care needs should be documented accurately. All staff should sign to confirm that they have received, read and understood the home’s adult protection policy and procedure. The identified rooms should be redecorated and a rolling programme of decoration continued. A full time maintenance person should be designated to Thomas Owen House DS0000001098.V303437.R01.S.doc Version 5.2 Page 24 4. YA24 5. 6. YA24 YA6 work only at the home. The carpet to the large lounge area should be replaced in line with the home’s redecoration plans. Daily records should reflect delivery of each service user’s plan of care. Thomas Owen House DS0000001098.V303437.R01.S.doc Version 5.2 Page 25 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.V303437.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!