Inspection on 10/05/05 for Tillson House

This inspection was carried out on 10th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tillson House 22/10/08

Tillson House 11/01/07

Tillson House 17/08/05

Tillson House 27/01/05

Tillson House 05/07/04

Tillson House 23/03/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

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

CARE HOMES FOR OLDER PEOPLE Tillson House Bradgate Drive Coalville Leicestershire LE67 4HF Lead Inspector Linda Clarke Unannounced 10 May 2005, 10:00am th 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. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Tillson House Address Bradgate Drive Coalville Leicestershire LE67 4HF 01530 832793 01530 832793 None Leicestershire County Council Social Services 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) Ms Carol Margaret Lomas Care Home 40 Category(ies) of Dementia (8), Dementia - over 65 years of age registration, with number (24) of places Learning disability over 65 years of age (4) Mental Disorder, excluding learning disability or dementia - over 65 years of age (6) Old age, not falling within any other category (40) Physical disability over 65 years of age (12) Sensory Impairment over 65 years of age (4) Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No person falling within category DE or DE(E) may be admitted to the home when 24 persons who fall within categories/combined categories are already accommodated within the home. No one falling within category MD(E) may be admitted to the home when 6 persons of category MD(E) are already accommodated. No one falling within category LD(E) may be admitted to the home when 4 persons of category LD(E) are already accommodated. No one falling within category PD(E) may be admitted to the home when 12 persons of category LD(E) are already accommodated. No one falling within category SI(E) may be admitted to the home when 4 persons of category SI(E) are already accommodated. Service users between the age of 55-65 years who fall within the above categories and were resident in the care home at the date of registration may continue to reside there. No one falling within category DE may be admitted into the home where there are 8 persons on category DE already accommodated. Persons falling within category DE may only be accommodated within the respite facility currently specialiseing in Dementia Care. No person under 55 years of age who falls within category DE may be admitted to the home. Date of last inspection 27th January 2005 Brief Description of the Service: Tillson House is a care home providing personal care and accommodation for forty older persons. Tillson House has a respite facility offering accommodation for upto eight individuals with Dementia, the facility being self contained within the home. The home is part of Leicestershire County Council, and is located close to town centre of Coalville. Tillson House is fully accessible, the home comprises of 40 single bedrooms, onf os which has en-suite faciities. Communal areas are provided on both the ground and first flloor, with access to the first floor via stairs or a passenger lift. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took place between 10.00am and 4.15pm. Opportunity was taken to look around the home, view records and policies which included viewing the care plans of five individuals residing at the home, time was also taken to talk to residents, visitors and staff including the Management team. What the service does well: What has improved since the last inspection? Improvement have been made in the administration and recording of medication Tillson House C51 S33449 Tillson House V225346 100505.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. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 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 Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 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) These standards were not inspected on this occasion. EVIDENCE: Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 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, 8, 9, 10 and 11. Residents are looked after well in respect of their health and personal care needs. EVIDENCE: Care plans provide good quality information about the care, health and social needs of residents – these are regularly updated with resident involvement. Daily records provide good and consistent information about the care being provided to residents, and demonstrate that concerns raised relating to residents are followed through promptly. Residents were observed as being treated with respect by staff, and this view was re-inforced through discussion with two residents who though the staff “were marvellous”. Improvements have been made in the recording and administration of medication; policies and procedures staff responsible for the administration of medication have attended a course in ‘The Safe Handling of Medicines’. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 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 standard(s) 12, 13, 14 and 15. Residents are provided with a good social and recreational programme which meets their needs; they have good opportunities to maintain contact with family and friends are supported well in exercising choice and control in their lives. Meals are well managed and of good quality. EVIDENCE: Both residents spoken to were very pleased with the food provided to them. One resident said ‘the cook is very good’. A menu of meals for each day is displayed near to the entrance to the dining hall, this offered choice including a vegetarian option for each meal. On the day of the Inspection, one resident was being visited by her daughter. Her daughter said that she could visit when she wanted, and that her mother came to her and her sister’s homes at weekends. Staff members take responsibility for arranging activities, and there is a good mixture of in-house entertainment arranged, and external entertainers coming to the home. Church services are also held within the home. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 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 standard(s) 16. Complaints are handled objectively and residents are confident that their concerns would be listened to, taken seriously and acted upon. EVIDENCE: The home has a detailed complaints procedure and complaint record. A relative raised a minor complaint since the last inspection, which was not related to residents. The staff at the home dealt with this complaint promptly. Discussions with two residents and a relative demonstrated a high degree of confidence that their complaints would be listened to and acted upon. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Residents live in a safe well-maintained environment, including a garden area. There is sufficient specialist equipment to maximise independence. EVIDENCE: Tillson House has recently undergone refurbishment, improving the décor of the home throughout. The main garden, and outdoor area attached to the respite unit. The bedrooms of five residents were viewed, and found to be comfortable and clean, and of a good standard of décor. The home has spacious sitting rooms on both the ground and first floor, which offers residents a variety of choices as to where to sit. The home provides sufficient lavatories and bathing/shower facilities to meet the needs of residents. Residents and relatives spoken to were all very satisfied with the levels of hygiene and cleanliness in the home. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 Page 13 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) 27, 28, 29 and 30. Staff at the home are well trained and supported, and employed in sufficient numbers to meet the needs of residents. EVIDENCE: Staff rotas indicated good levels of staffing which were sufficient to meet the needs of residents at the time of the Inspection. Management are proactive in ensuring that there is sufficient staff cover to deal with sickness, annual leave and training, the management team varies staffing levels to meet the individual needs of residents. The Local Authority has in place a departmental training plan; the document details general areas of training and training specific to the needs of residents. Staff training records reflected a variety of topics including health and safety, adult protection, care practices and specifically training in Dementia. A significant number of staff has attained a National Vocational Qualification level 2 or 3 qualification, with some working towards. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 Page 14 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) 31, 32, 33, 36 and 38. The Registered Manager offers a clear sense of leadership, which reflects on the day-to-day delivery of care practices of residents and running of the home. EVIDENCE: The management team were observed to work well together, and have a good understanding of each other’s roles and responsibilities. The Registered Manager and Deputy Manager are currently working towards an National Vocational Qualification level 4. The two Assistant Managers have an National Vocational Qualification level 2, with one Assistant Manager being a qualified Assessor of National Vocational Qualifications. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 Page 15 Records within the home are in good order, and the key working system works well to provide residents with continuity of care. A member of staff informed the Inspectors of her satisfaction with the key worker system and sited it as being very effective in promoting good quality care to residents. The member of staff also has supervision every 3 months, and is given access to course that seen by both her and the management team as useful in the continuation or improving services for residents. Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 Page 16 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 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 4 4 3 x x 3 x 3 Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 Page 17 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Tillson House C51 S33449 Tillson House V225346 100505.doc Version 1.30 Page 18 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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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