CARE HOMES FOR OLDER PEOPLE
Tolson Grange 12 Coach House Drive Dalton Huddersfield West Yorkshire HD5 8EG Lead Inspector
Jacinta Lockwood Unannounced Inspection 23rd January 2006 10:55 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 Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 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. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Tolson Grange Address 12 Coach House Drive Dalton Huddersfield West Yorkshire HD5 8EG 01484 432626 01484 519126 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) Anchor Trust Mr Jason Corrigan Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: Tolson Grange is a home providing personal care and accommodation for up to twenty-four older people with dementia. Anchor Trust, a national housing association and organisation providing residential care own the home. Tolson Grange, which is located on the outskirts of Dalton a residential suburb of Huddersfield, was purpose built. The home has twenty-four large, single ensuite bedrooms with privacy locks and good communal facilities over two floors. Stairs and a shaft lift are available to allow access to the upper floor. The home has enclosed sloping gardens. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection on 23 January 2006. The inspection lasted approximately 6.5 hours. The following inspection methods were used: observation, discussion with two visiting relatives, four service users, staff and management. Inspection of a sample of records including service user care plans, risk assessments, monies, food records, staff training and recruitment, fire safety. A limited tour was made of the building. At the time of the inspection there were 20 service users at the home. There are currently two service user vacancies. What the service does well: What has improved since the last inspection?
Some requirements and recommendations from the previous report have been addressed. The home’s recruitment practices are more robust and fuller information obtained so the right people are employed to work with vulnerable adults. Staff have received training in infection control to promote good hygiene. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 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. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 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 Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 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): 3 Service users’ needs are assessed before they move into the home. EVIDENCE: Standard 6 is not relevant. Tolson Grange does not provide intermediate care. Pre admission assessments were available on those files seen. There have been no new admissions to the home since the last inspection. However, standard documentation confirming that the home can meet a service user’s assessed needs is available for use. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 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 Not all service users’ needs are set out in the plan of care. EVIDENCE: The home’s manager explained that new care planning documentation is to be introduced in the near future. This should support improvements which need to be made to care plans, so that a person’s needs and goals, and the interventions that staff need to make to support the service user, are recorded, specific and clearly set out. Two care plans were inspected. Service user reviews have taken place, but care-planning documentation had not been updated to incorporate newly identified needs. Where a short-term need requires intervention, a care plan must be produced. There was some conflicting information within the documents and entries were not always signed and dated so it was difficult to assess the currency of information. Also, daily records need to show which elements of the care plan have been delivered and any outcomes to that care. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 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): 15 Service users receive a wholesome appealing diet suited to their needs. EVIDENCE: The food provided at the home is freshly prepared, wholesome and wellpresented and home baked pastry dishes and sweet cakes are also provided. Special diets are catered for and kitchen staff were aware of people’s needs. Where appropriate staff monitor service users’ food and drink intake, providing nutritional supplements where required following discussion with the service user’s GP. Monitoring records are also kept. Service users received positive feedback from staff. And staff supported a service user, by showing the puddings, so that the service user could choose. Service users are offered a choice of foods and they commented positively on the food provided. A visitor was aware that a meal could be taken with their friend/relative if they wished. Staff offered a visitor a drink and biscuits on arrival. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 Page 11 The majority of service users ate in the dining room although the lounge area was also used by choice. The meal was unhurried with service users being given enough time to eat. The manager explained that new tablecloths are to be purchased to enhance the dining environment. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 Page 12 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): Standards not assessed on this occasion. EVIDENCE: Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 Page 13 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, 26 Service users live in a generally well-maintained and safe environment. The home was clean, pleasant and hygienic. EVIDENCE: These standards were only assessed to follow up a previous requirement and recommendations. Recommendations have been carried forward. However, the manager explained that a new emergency call system is to be installed and that in the meantime night-time checks have been increased and staff made aware of the need to be more observant throughout the day. The home is to be redecorated and re-carpeted in the near future and new seating and coffee tables have been ordered. New light fittings are in place. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 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): 28, 29, 30 NVQ training is ongoing at the home to ensure that service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment practices. Staff receive training so that they are competent. EVIDENCE: Standard 28 relates to NVQ training. The home’s NVQ assessor explained that NVQ training is ongoing and staff confirmed this. Currently 37 of staff are qualified to NVQ level 2 or 3 and 10 staff are working towards the qualification. Progress needs to continue so that a minimum of 50 of staff are NVQ qualified. A recommendation is carried forward. Standard 29 was assessed to follow up a previous recommendation, which has been addressed. It is positive to note that the manager contacts referees to confirm the authenticity of references. Standard 30 was assessed to follow up a previous recommendation regarding infection control training. Training was being delivered to staff on the day of the inspection by an infection control specialist and attendance certificates seen. Staff made positive comments about the training provided. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 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): 33, 35, 37 The home is run in the best interests of service users. Service users’ financial interests are safeguarded. Service users’ rights and best interests are generally safeguarded by the home’s record keeping. EVIDENCE: The financial records and monies held on behalf of service users were easily reconciled and receipts were available. Standards 33 and 37 were only assessed to follow up previous requirements and a recommendation, which have been addressed. The manager explained that a quality assurance questionnaire is being sent out this month. Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 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 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X 2 X X X 2 STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X 3 X Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 Page 17 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 15(1) Requirement All of the service user’s identified needs must have a corresponding plan of care which details how those needs are to be met. (Timescale of 03.12.05 not met). Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care planning information needs: • to be more specific so that clear instructions are available to staff as to how they are to meet service users’ health and welfare needs consistently; • to be signed and dated so that the currency of the information is clear; • to include risk assessment findings; • to be completed accurately Daily reports on service users should clearly reflect delivery of the care plan and the outcomes to that care.
DS0000026339.V266476.R01.S.doc Version 5.1 Page 18 2. OP7 Tolson Grange 3. OP22 Service users should have access to call bell leads for attracting the attention of staff. (Recommendation carried forward.) The registered person should ensure that evidence is made available for inspection that the services and facilities at the home comply with the Water Supply (Water Fittings) Regulations 1999. (Recommendation carried forward). The registered person should ensure that a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved. (Recommendation carried forward). 4. OP26 5. OP28 Tolson Grange DS0000026339.V266476.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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