Inspection on 03/08/05 for Thomas Tawell House

This inspection was carried out on 3rd August 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 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 Tawell House 04/01/06

Thomas Tawell House 10/01/05

Thomas Tawell House 26/07/04

Thomas Tawell House 09/03/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Pocklington House

Bilney Hall

Hill Barn

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

CARE HOMES FOR OLDER PEOPLE Thomas Tawell House Magpie Road Norwich Norfolk NR3 1JH Lead Inspector Linda Wells Unannounced 3 August 2005 at 11.45am rd 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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Thomas Tawell House Address Magpie Road, Norwich, Norfolk. NR3 1JH. 01603 629558 01603 766682 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) Norfolk & Norwich Association For The Blind Mrs Sharon Patricia Gaul Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37), Sensory impairment (37) of places Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 37 residents up to five at any one time may be between the ages of 50 and 65. Date of last inspection 10th January 2005 Brief Description of the Service: Thomas Tawell House is a two storey building that is run as a residential care home for thirty seven older people who are partially sighted or blind and forms part of the facilities of the Norfolk and Norwich Association for the Blind. An extensive refurbishment programme in 2000 has provided excellent facilities for service users in thirty two single rooms with ensuite facilities. There are four single rooms with lavatories and wash basins, and one room with a wash basin attached. The home has a passenger lift to the first floor and contains all the equipment and adaptations to make life safe and comfortable. There is communal access to five lounges (including a quiet room), a dining room, six bathrooms, one shower room, nine toilets and a telephone kiosk. The Home is located in the well kept grounds of the Association next to the Equipment and Information Centre and a building called The Allen Centre. The Allen Centre is a place where craft, IT, Living Paintings Trust, Braille and Moon classes are taught. There is parking to the front of the building and the home is situated not far from local health and shop facilities and within walking distance of the city centre of Norwich. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 3rd August 2005 over four hours and was carried out as part of a routine inspection plan. On the day of inspection twenty-nine residents were living at the home and were seen to be having a meal, sitting in the lounges, their bedroom or the garden listening to the radio, reading or watching television. The inspection took the form of a tour of the premises, individual discussion with four residents, three staff members and the assistant head of home, group discussion with one resident and two visitors, examination of care plans, records, certificates and compliance of requirements and recommendations from the last inspection. What the service does well: What has improved since the last inspection? The garden of the home has been made more attractive by the purchase of additional plants and new garden furniture resulting in the home winning the ‘Garden in Bloom Award 2005’. Some residents have been active and took part in the Sandringham Show this year and exhibited the craft items they had made in the craft class at the home. They were proud and pleased to receive a Royal visitor to their exhibition and to be complimented for their craft abilities and efforts. Residents are being helped to keep fit and a new weekly ‘Extend’ exercise class has been introduced to the home and is enjoyed by all who attend. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 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 Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 5 The admission procedure and written information available is good and fully enables residents and staff to make a decision on whether the home will meet the needs of anyone wishing to live there. EVIDENCE: The homes Statement of Purpose, Service User Guide and Terms and Conditions contract were seen and found to contain relevant information. The assistant head of home said that prior to admission as much information as possible was collected from a prospective resident, their family and other professionals. She said residents, their family or friends sometimes visited the home, that she or the manager often visited residents in their own home and that residents were admitted on a one-month trial basis. One resident spoken to who had lived at the home for seven weeks said that he had visited the home prior to admission, had received information about the home and that staff had made him feel welcome and assisted him to settle in. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9, 11 The health, social and personal care needs of residents were met, they were well cared for but records were not all fully up to date. EVIDENCE: Residents said they were well looked after and four individual plans of care were examined and found to contain relevant health, social and personal care information, daily records, risk assessments, choices, routine and visiting professionals. However, they did not contain a photograph of the resident and although a photograph of each resident was held in their file in the main office this was not accessible to staff members and a recommendation was made that a photograph be held in the plan of care and/or medication records of each resident. In addition the wishes of each resident upon death and regular reviews with residents were not carried out and a further two requirements were made that the wishes of residents at death be recorded and reviews be carried out with each resident every month to demonstrate involvement, consultation and agreement of each resident on their funeral arrangements and plan of care. Medication policies seen protected residents, records showed that staff had undertaken training and medication was seen to be stored correctly but in three instances seen the procedure held had not been followed and the Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 10 medication administered had not been signed for. A requirement was made that all medication administered be signed for or a code used to identify why it had not been administered. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 There are some social and creative activities but they do not fully meet the interests of the residents and the standard of the meal option provided for tea varies. EVIDENCE: Residents said that they were not fully stimulated by the activities provided and records were seen to demonstrate that some activities were provided such as the craft class and Extend. The assistant head of home said that there was occasionally bingo and at least once a month outside entertainment was arranged. She gave an example of the summer B-B-Q that had taken place in July and the two visitors spoken to said that they joined in with the homes organised events and were always made to feel welcome in the home. A recommendation was made that a review of the activities provided is undertaken with residents to ensure resident choice and to produce a program of activities. The assistant head of home said that there was a key worker scheme in place in the home but the residents said that they were not aware of who their key worker was and staff were unclear on the role of a key worker. A recommendation was repeated that the key worker scheme is further developed to ensure residents have a member of staff to relate to and staff members understand the role. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 12 The main meal and menus were seen and were balanced and varied. Records showed that residents were given a choice and an alternative offered. However, everyone spoken to said that the standard of the meal option provided for tea could sometimes be poor and a recommendation was made that a review of the meal option for tea be carried out with the residents. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has an active procedure on the protection of vulnerable adults that protects residents and supports the investigation of any cause for concern. EVIDENCE: No complaints have been received by the home and the residents spoken to all agreed that if they had reason to complain they would speak to staff or the assistant head of home and all felt confident that the problem would be resolved quickly and to the satisfaction of all involved. Residents are protected from abuse, neglect and self-harm by the objectives, policies and procedures of the home and records showed that staff have undertaken training in Adult Abuse to help them recognise, prevent and deal with any potential abuse. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 24, 26 The standard of the environment within this home is very good providing residents with an attractive, safe and homely place to live. EVIDENCE: A tour of the building revealed that residents benefit from a home that is bright, airy and decorated and furnished to a high standard. It contained all of the adaptations, specialist equipment and flooring suitable for those who are partially sighted or blind. Residents said that they lived in a home that was comfortable and that the home was clean, tidy and odour free. This was found during the tour of the building and residents were seen to have personalised their bedrooms. Residents had the use of en-suite facilities, communal bathrooms and toilets on each floor that were adapted to suit the needs of the residents. Infection control measures were in place but a requirement was made that the sluice room be locked when not in use to protect resident. The assistant head of Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 15 home arranged for a key to be provided for the sluice room during the inspection. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29, 30 The needs of residents are met, staff members are competent, but the procedure for the recruitment and training of staff does not fully provide safeguards to offer protection for the people living at the home. EVIDENCE: Residents said that they were well cared for and the staff spoken to said that there were enough staff on duty to meet the needs of each resident if all shifts were covered in times of sickness and annual leave. The three staff members spoken to said that they were supported by the senior care staff, assistant head of home and the manager, handover, staff meetings and supervision and demonstrated that they were aware of their role and responsibilities. Records showed that residents were not fully protected because all staff recruitment checks had not been carried out. Although CRB checks, references and personal details were held on each member of staff no proof of identity was held for any staff member and a requirement was made that proof of identity and a photograph of each staff member be held in each staff file. Records demonstrated that staff members had a mix of experience and skills and those spoken to had all completed NVQ2 and one staff member NVQ3 training. Certificates showed that an induction, foundation and updated training programs were undertaken by all staff to enable them to gain the knowledge necessary for the range of needs of residents living at the home. However, the assistant head of home who had worked at the home for five Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 17 years had not undertaken any basic training nor NVQ training and a requirement was made that she commence NVQ training suitable to her role. Staff spoken to gave examples of caring for residents who occasionally exhibited challenging behaviour and although they all said that they were given support from the senior staff and health professionals they all demonstrated that their knowledge was incomplete. Therefore, staff and residents would benefit from staff undertaking training in caring for those with challenging behaviour and a requirement was made. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 37, 38 The manager is supported by the senior staff in providing leadership, guidance and direction to staff to ensure that residents receive a good standard of care. EVIDENCE: Residents said that the home was well run and records demonstrated that residents are protected by the management and administration procedures carried out in the home. Policies and procedures have been produced and were seen on all aspects of the home and service provided. The records held were found to promote and protect the rights and best interests of each service user. The handover, staff meeting minutes and staff review records demonstrated that staff members worked as a team and were supported and regularly supervised by the senior staff to ensure that their knowledge of the needs of each resident, their work practice, commitment and training needs were identified, clarified and reviewed. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 19 The servicing and testing of all equipment had been carried out and relevant and timely certificates were held to ensure that the health and safety of residents is protected. Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 2 COMPLAINTS AND PROTECTION 3 x 2 3 x 3 x 3 STAFFING Standard No Score 27 x 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x x 3 3 Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 21 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. 1. Standard OP7 Regulation 15.2.b Requirement The registered person must ensure that a monthly review of care is undertaken with each resident. The registered person must ensure that all medication administration records are completed. The registered person must ensure that the wishes and arrangement at death of each serice user are recorded in their plan of care. The registered person must ensure that service users are protected and that the sluice room is kept locked when not in use. The registered person must ensure that all staff receive training appropriate to their role. The registered person must ensure that all recruitment checks are completed on all staff and records held. The registered person must ensure that staff undertake training in caring for those with challenging behaviour. Timescale for action 1st October 2005 and ongoing 1st September 2005 and ongoing 31st December 2005 1st September 2005. 31st December 2005 31st December 2005 31st March 2005 2. OP9 17.1.a schedule 3.3.i 12.3 3. OP11 4. OP21 13.4.c 5. 6. OP28 OP29 18.1.c.i 19.1-5 schedule 2 18.1.c.i 7. OP30 Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 22 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. Refer to Standard OP7 OP12 Good Practice Recommendations It is recommended that the photgraph of each service user held in the home is kept in the plan of care and/or medication records to aid identification. It Is recommended that a review of the activities provided is undertaken with the service users to ensure their leisure wishes and choice are considered and to produce a program of activities. It is recommended that further development of the key worker scheme takes place to ensure all service users have a staff member to relate to. It is recommended that a review of the meal option at tea is undertaken with service users to ensure variety and that their choice is considered. 3. 4. OP13 OP15 Thomas Tawell House I55 s27299 Thomas Tawell v241693 UN 030805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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