Inspection on 11/01/07 for Tillson House

This inspection was carried out on 11th January 2007.

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 17/08/05

Tillson House 10/05/05

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 Lee West Key Unannounced Inspection 11th January 2007 13:00p 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 Tillson House DS0000033449.V323941.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 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 DS0000033449.V323941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tillson House Address Bradgate Drive Coalville Leicestershire LE67 4HF 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) 01530 832793 01530 832793 www.leicestershire.gov.uk Leicestershire County Council Social Services Ms Carole Margaret Lomas Care Home 40 Category(ies) of Dementia (8), Dementia - over 65 years of age registration, with number (24), Learning disability over 65 years of age of places (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 DS0000033449.V323941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Categories DE & DE(E) 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 PD(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 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 specialising in Dementia Care No person under 55 years of age who falls within category DE may be admitted to the home To be able to admit a person under the age of 65 named in variation application number V22487 To be able to admit a person under the age of 65 years named in variation application number V27125 dated 21:11:05 17th August 2005 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Date of last inspection Brief Description of the Service: Tillson House is a residential care home providing personal care and accommodation for up to forty older persons. Tillson House is fully accessible, with communal areas and bedrooms being located on both floors. Accommodation is provided over two floors with access between floors being via stairs or a passenger lift. The forty single bedrooms are without en-suite facilities. The Garden, with seating areas, mature plants and trees, is accessible to residents. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 5 Tillson House also has a respite facility offering accommodation for up to eight individuals with Dementia. The facility, called “Beacon Villa” is self contained within the home. Owned by Leicestershire County Council Social Services Department Tillson House is situated close to the town centre of Coalville, offering all local amenities and is accessible by private or public transport. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, over 5 hours, starting at 13:00pm. The Registered Manager, Carol Lomas, was present and assisted throughout. The method used was Case Tracking. A number of service users were spoken with about their experiences and expectations of living at the home. Their care plans and other records, prepared and made available by the manager, including the pre-inspection questionnaire, were analysed. A tour of the premises was also undertaken to see the rooms used by service users case tracked and also the Beacon Villa facilities. Staff, visiting professionals, and other visitors’ views were also sought to inform the judgements within this report. What the service does well: What has improved since the last inspection? What they could do better: There are activities within the home, entertainers, a pat dog and an activities person goes around and gets small groups involved in activities. But, activity Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 7 programmes could be more structured and interactive with staff to help with the mental stimulation needed to try to preserve the memory functions of service users, and could include activities to promote physical activity too, for example, movement to music. A service user said, “I just sometimes feel I want to stretch my arms and legs.” 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. The summary of this inspection report can be made available in other formats on request. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 8 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 Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users’ needs are thoroughly assessed and service users admitted for respite care are assisted to maximise their independence to return home. EVIDENCE: Care plans case tracked, included thorough assessment of service users’ needs. They included information from service users and their relatives, about life history as well as medical history and care needs, which was seen to help the development of the care plans. One service user admitted for intermediate care said, “If I needed a home full time, this is where I would like to be.” Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans are person centred to meet individual service user’s needs. Medication procedures are appropriately followed and service users are treated with respect. EVIDENCE: Care plans case tracked were person centred, identified the service user’s personal preferences, medical and personal histories, and, following the thorough assessment, provided a holistic approach to the individual’s needs. Service users spoken with said they were happy that their needs are met. “I’ve never known anywhere where I’ve been better looked after.” I’m always dressed lovely, and I even get my pearls put on for me,” were comments made by service users. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 11 During the inspection there were a number of visitors present, who spoke with the inspector. They commented, “the staff are always helpful, very caring and provide a really excellent service.” One professional visitor said, “The Beacon Villa unit is exceptional. If it can’t manage a person, no-one else would be able to and the person would have to go into hospital.” Medication was stored securely and appropriately and all Medicine Administration Records case tracked, were accurately completed and signed. Medication, given during the inspection, was according to the procedures. One service user said, “I know I could look after my own medicines, but I feel much safer with the staff doing it.” Service users spoken with said the staff treated them with respect and maintained their dignity at all times. “They always knock before coming into my room,” a number of service users said. Staff spoken with said they were encouraged to promote dignity and privacy, by the manager, but did this anyway. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are encouraged to make choices and maintain contact with their families. Tillson House identifies personal preferences, religious and recreational interests and needs and these are generally met. EVIDENCE: Care plans, inspected, identify personal preferences, religious and recreational interests and needs, which they generally address. However, whilst the service users were obviously enjoying joining in with the Daniel O’Donnell DVD playing on the television in the lounge area after lunch, there were no members of staff in the lounge, at the time, to interact with them. Service users spoken with during this activity said,“I love his voice and love to sing along with him.” Entertainers perform at the home and there are regular visits from the “pat dog”, which service users said they enjoyed. There is also an activity worker Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 13 who takes small groups and plays dominoes scrabble and some reminiscence therapy.” In view of the number of service users, and their varying degree of need, programmes could be more structured and interactive with staff to help with the mental stimulation needed to try to preserve the memory functions of service users, and could include activities to promote physical activity too, for example, movement to music. A service user said, “I just sometimes feel I want to stretch my arms and legs.” Contact with family and friends is encouraged at Tillson House and they are encouraged to be involved with the quality assurance, as well as supporting their relatives. A visitor present discussed the meetings and their purpose. “ We’re getting funds for a raised flowerbed at the moment.” Service users were observed to be offered choices, and staff encouraged service users to make decisions. This was particularly seen during the mealtime, when choices of food were offered. The food was appetising, wholesome and served in a pleasant dining area. The menus were seen to be varied and balanced. There was also a licensed bar in the corner and service users were given opportunities to buy an alcoholic drink if they choose to. Service users spoken with said they enjoyed this facility. “Its more like being at a hotel with friends, than in care,” a service user commented. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and procedures are in place for the protection of adults from abuse. EVIDENCE: Several visitors, spoken with, said that if they had any problems they would go to the manager, Carole, who would immediately deal with the problem. They said, they were also involved in the regular meetings where they could air any problems. Staff spoken with confirmed they would report any concerns to the manager and, during discussions, they demonstrated their knowledge of the procedures in protection of vulnerable adults, consistent with guidelines, which helps protect service users from any forms of abuse. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Tillson House provides a safe standard of accommodation and Beacon Villa within, is decorated in an innovative way, which aids sufferers of dementia. EVIDENCE: Beacon Villa has been decorated and now uses a system which, blends areas service users should avoid, for example the door to the kitchen area, by using the same colours as the wall. Doors to other areas, such as bedrooms, toilets and lounge door, are painted in a bright colour, which has reduced the episodes of service users becoming confused and lost. This unit also provides a homely atmosphere and pleasant furnishings for the service users. Tillson House is well maintained, clean and hygienic. Although a large unit, the communal lounges on the ground and first floor provide choices of where to sit. There is a sitting room available for individuals who smoke. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 16 The service user’s personal rooms are clean and pleasantly decorated, with personal possessions around them. Service users commented how much they liked their rooms. One comment made was, “I love this room I can see out over the garden and see the birds.” There are sufficient toilets and washing facilities, although none of the rooms are ensuite, with a new track hoist in an upstairs bathroom to aid moving of service users with mobility difficulties. Specialist equipment was seen to be available, with service users using a variety of aids, zimmer frames, sticks and there is one bedroom with an overhead track hoist to support service users to be as independent as possible. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are suitably recruited, trained and employed in sufficient numbers to meet the needs of the service users. EVIDENCE: Staff files inspected contained evidence of thorough recruitment procedures, Criminal Records Bureau checks, references and signed contracts, which support the safeguarding of service users. Training records were seen, which evidenced the training in a number of areas, including, Induction of new team members, First Aid, Dementia Care and National Vocational Qualifications, indicating the management’s support of staff to be competent to do their jobs. There were sufficient numbers of staff on duty to meet the needs of the service users. In Beacon Villa, there was only one staff member, with eight service users present. However, others from Tillson House supported this staff member, when required. The staff member was spoken with and confirmed there was always staff available to support in Beacon Villa, when it was necessary. This was also Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 18 evidenced on the duty rota with “BV link and BV meds” identifying the members of staff responsible at particular times to provide this assistance. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The registered manager carries out her role with a strong leadership style, which supports the health, safety and welfare of service users and staff. EVIDENCE: The registered manager has strong, clear, leadership skills, which were observed during this inspection. She has achieved a Dementia Care Mapping Certificate from Bradford University, which influences her role to support service user and their interests. Service users spoken with said, “Carole is always helpful and listens.” Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 20 Meetings with service users and relatives are regularly held and the outcome from these meetings is used to improve the services provided. Surveys from the service users and others are gathered together and graphs were shown on the notice board, and help to improve the services. Staff interviewed, commented that the manager was always supportive of them and that she listened to their suggestions. Records of regular supervision and appraisal were seen in the staff files case tracked and staff spoken with confirmed that this was carried out regularly\by members of the management team. The pre-inspection report submitted by the manager provided evidence of the regular maintenance and safety checks undertaken to protect the service users and staff at the home. Records confirming this were seen during the inspection visit. Service users and visitors spoken with were satisfied that the home was run in the best interests of the service users and they were also kept safe. “I’ve never been anywhere where I have been where I have been better looked after.” “I can help myself a lot, but carers help me when I need it and don’t try to take over.” “If I needed a home permanently, this is where I would like to be.” Were comments made by a number of the service users. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 21 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 3 3 3 X X 3 X 3 Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? none 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. 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 OP12 Good Practice Recommendations Activity programmes would be improved if more structured and interactive with staff to help with the mental stimulation needed to try to preserve the memory functions of service users, and could include activities to promote physical activity too, for example, movement to music. Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Tillson House DS0000033449.V323941.R01.S.doc Version 5.2 Page 24 - 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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