Inspection on 04/01/06 for Thomas Tawell House

This inspection was carried out on 4th January 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 but made no statutory requirements on the home.

Other inspections for this house

Thomas Tawell House 03/08/05

Thomas Tawell House 10/01/05

Thomas Tawell House 26/07/04

Thomas Tawell House 09/03/04

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Oak Ridge

Coopers Mill Ltd

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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 Inspection 4th January 2006 11.00 X10015.doc Version 1.40 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 Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000027299.V268575.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thomas Tawell House Address Magpie Road Norwich Norfolk NR3 1JH 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) 01603 629558 01603 766682 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 DS0000027299.V268575.R01.S.doc Version 5.0 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 3rd August 2005 Date of last inspection 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 en-suite facilities. There are four single rooms with lavatories and washbasins, and one room with a washbasin only. 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 a small amount of parking to the front of the building and the home is situated close to local health and shop facilities and is within walking distance of the city centre of Norwich. Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 04th January 2006 over five hours and was carried out as part of a routine inspection plan. Prior to the inspection nineteen comment cards were received from residents, twenty-two from relative/visitors and one from a visiting professional. All of those who returned the comment cards indicated that they were satisfied with the overall standard of care provided, that the home was always clean, staff members were caring and residents were well cared for. Relatives/visitors wrote, “the care given is wonderful” and “staff are friendly, first class”. On the day of inspection thirty-one residents were living at the home and were seen to be having a meal, sitting in the lounges or their bedroom listening to the radio or taking part in a church service. The inspection took the form of a tour of the premises, individual discussion with four residents, three staff members and the manager, group discussion with three residents, 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? Residents and staff have benefited from the information held being completed, further development of the key worker scheme and residents being consulted. Residents have enjoyed a series of NNAB Bi-Centenary 200years celebrations, an increased program of activities, the redecoration of four bedrooms and the refurbishment and redecoration of the kitchen. Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 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 DS0000027299.V268575.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 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 the following standard(s): 1, 4, 6 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 manager 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 assistant head of home 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 three months 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 DS0000027299.V268575.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9, 10, 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 have improved and to contain relevant health, social and personal care information, daily records, choices, capabilities, funeral details, photograph, routine and visiting professionals. However, they did not contain a record of the weight of the resident and although risks to the resident were identified there was no written assessment of risk prevention and management and two requirements were made. Residents were protected by the medication policies and the improved procedures seen. Records showed that staff had undertaken training and that medication was administered and stored correctly. Residents spoken to said that staff treated them with respect and that their privacy was upheld. The records held on the arrangements at death for residents demonstrated that they had been consulted and their wishes were known. Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 12, 13, 14, 15 The social and creative activities and meals provide some daily variation and interest for those living at the home. EVIDENCE: The manager said that it was often difficult to stimulate residents and although improvements had been made to the planned activities and residents meetings had taken place to discuss the range of activities residents would like to take part in only a minority of residents showed an interest. Residents spoken to said that they enjoyed some of the activities such as craft and all said “there are activities available if you wish to join in”. Residents spoken to said that staff were friendly, gave them every chance to make a choice in their daily lives and that staff made their relatives and visitors welcome when they visited the home. Residents all said that they enjoyed most of the meals and two spoken to said that their special dietary needs were catered for. Observation of the main meal, menus and records revealed that they were balanced, wholesome and varied and that records were kept of any alternatives provided to aid in the monitoring of the nutritional health of each resident. However, the tea option is prepared at lunchtime and residents and staff said that it was sometimes not at it’s best by teatime. A recommendation was made that consideration be given to preparing the tea meal just prior to the meal being eaten. Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 16, 17, 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 manager and all felt confident that the problem would be resolved quickly and to the satisfaction of all involved. The legal rights of residents are protected and records demonstrated that some residents have advocates and are encouraged to take part in the local and national elections by voting. 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 DS0000027299.V268575.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 19, 21, 23, 25, 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. However, the carpets in some bedrooms were very stained and a recommendation was made that they be deep cleaned to make the rooms more attractive. Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 13 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 and infection control measures were seen to be in place. Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 14 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The needs of residents are met, staff members are competent and the procedure for the recruitment and training of staff provides safeguards to offer protection for the people living in 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 and if the dependency of residents staying at the home for a short stay were not high. 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 years had not undertaken any basic training nor NVQ training and a requirement was repeated that she commence NVQ training suitable to her role. The manager said that the assistant head of home was waiting to commence NVQ3. Records have improved and showed that residents were protected by the staff recruitment checks that had been carried out. CRB checks, references, personal details, proof of identity and a photograph of each staff member were seen to be held in the file of each staff member. Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 15 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36, 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: The manager has been in post for two years, has sixteen years past experience of working in the care setting and has completed the NVQ4 Registered Managers award. Residents and staff members said that the home was well run and that the manager was approachable. Records demonstrated that the management, accounting and financial administration procedures carried out in the home offer safeguards and protect residents. The staff members spoken to said that they were supported by the senior staff, assistant head of home and the manager, handover and staff meetings and were aware of their role and responsibilities. Records held showed that only Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 16 the senior staff received regular supervision and a requirement was made that all staff receive supervision a minimum of six times a year to ensure that their knowledge of the needs of each resident, their work practice, commitment and training needs are identified, clarified and reviewed. A Quality Assurance system is in place but does not take into account the views of everyone living, visiting and working in the home and a requirement was made that the system must be further developed to include the feedback and views of residents, short stay residents, relatives, visitors, staff members and other professionals to ensure everyone is consulted and an action plan produced. 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 manager successfully monitored identified financial budgets for the home and there was no reason to doubt that the financial security of The Norfolk and Norwich Association for the Blind was not sound. 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 DS0000027299.V268575.R01.S.doc Version 5.0 Page 17 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 X 2 X 3 X STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 2 X 3 Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 18 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. Standard OP7 Regulation 13.4.a-c Requirement The registered person must ensure that written risk assessments are completed for all residents. The registered person must ensure that a record of the weight of each resident is held in his or her plan of care. The registered person must ensure that the assistant head of home undertakes training appropriate to her role. (Previous timescale of 31st December 2005 has not been met.) The registered person must ensure that the Quality Assurance system carried out in the home is further developed. The registered person must ensure that all staff receives regular supervision and records are held in their staff file. Timescale for action 31/03/06 2. OP8 12.1 30/04/06 3. OP30 18.1.c.i 31/03/06 4. OP33 24.1.2 30/06/06 5. OP36 18.2 31/03/06 Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 19 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. Refer to Standard OP15 Good Practice Recommendations It is recommended that consideration be given for the tea options to be prepared just prior to tea being served and not at lunchtime to ensure the quality of the food provided for residents. It is recommended that the bedroom carpets that are stained be deep cleaned to make them more attractive. 2. OP23 Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Norfolk Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Thomas Tawell House DS0000027299.V268575.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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