Inspection on 03/10/05 for Tolson Grange

This inspection was carried out on 3rd October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tolson Grange 21/10/08

Tolson Grange 30/10/07

Tolson Grange 21/11/06

Tolson Grange 23/01/06

Tolson Grange 11/02/05

Tolson Grange 08/07/04

Tolson Grange 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Tolson Grange 12 Coach House Drive Dalton Huddersfield West Yorkshire HD5 8EG Lead Inspector Jacinta Lockwood Unannounced Inspection 3rd October 2005 11:45 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.V256966.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. Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 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.V256966.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th February 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.V256966.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection on 3 October 2005. The inspection started at 11.45am and ended at 17.15 hours. There were no service user vacancies at the time of the inspection. The following inspection methods were used: inspection of a sample of records including care plans, risk assessments, medication records, activities records, complaints documentation, staff recruitment and training records, staffing rota, staff meeting minutes, equipment service records. A limited tour was made of the premises. The inspector also spoke with service users, a relative, staff and management. What the service does well: What has improved since the last inspection? Progress is being made towards meeting the National Minimum Standards for Older People and The Care Homes Regulations 2001 with a number of requirements and recommendations from the last inspection having been addressed. The employment of an activities co-ordinator means that service users’ interests and hobbies are being addressed. Formal and informal support for service users, staff and relatives is being provided through the use of an advocacy service, the involvement of Community Psychiatric Nurses and relatives meetings. A more comfortable environment is being provided for service users as maintenance and refurbishment work is progressed. The home’s manager is now registered with the Commission for Social Care Inspection as being fit to manage the home. Tolson Grange DS0000026339.V256966.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. Tolson Grange DS0000026339.V256966.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 Tolson Grange DS0000026339.V256966.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): 3 Service users’ needs are assessed before they move into the home. But they do not receive written confirmation that the home can meet their assessed needs. EVIDENCE: Standard 6 is not relevant as Tolson Grange does not provide intermediate care. Pre-admission assessment information was available on those files inspected. There was no evidence that the service provider has given written confirmation to the service user that their needs could be met at Tolson Grange as required under The Care Homes Regulations 2001. A requirement is made. Tolson Grange DS0000026339.V256966.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 Not all of the service user’s needs are included in their individual plan of care. Service users are supported to make decisions and are treated with respect. Service users are protected by policy and practice regarding medication. EVIDENCE: Each service user has an individual plan of care based on their assessed needs. The plans are kept under review monthly by staff. The service user’s representative, usually the next of kin, is involved in reviewing the plan at sixmonthly intervals. Although there was evidence that relatives had signed care plans, not all the plans seen had been signed. Risk assessments were completed, including falls. Although relevant information was held on the service user’s file, the information was not easily accessible and not all identified needs had a corresponding plan of care. A requirement is made. To allow care to be provided in a consistent manner, information in care plans needs to be more specific. For example, entries such as ‘wears pads’, ‘likes to go to bed at a certain time’, ‘check regularly’ do not provide sufficient detail to allow care to Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 10 be provided in a consistent manner. More attention should be paid to daily reporting, because entries did not clearly reflect the actual care provided each day nor whether the desired outcome for the service user was being met. Recommendations are made. The registered manager explained that a new care-planning format is to be introduced which will, hopefully, address current shortfalls in care planning. A range of healthcare professionals including GP’s, District Nurses, Optician, Chiropodist and Community Psychiatric Nurses, meet service users’ healthcare needs. Staff had a good understanding of the service users’ care and support needs. And service users looked well groomed and cared for. They were offered choice with regard to food, drinks and activities and were able to move freely around the home. Staff were seen to treat service users with respect and to uphold their privacy. Service users who were able to comment made positive remarks about the care provided by staff. A relative also expressed satisfaction with the care provided at the home. Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 Service users are supported to maintain contact with family, friends and the wider community. They have opportunities to exercise choice in their daily lives and to engage in social and leisure activities. EVIDENCE: An activities co-ordinator is now employed. It was evident that a lot of work has gone in to finding out what service users’ interests and hobbies are and that their family or friends have been involved in this. The activities coordinator is establishing links with other agencies to develop her knowledge and skills so that service users can access activities within the home and the wider community that would be of interest and benefit to them. Examples of activities are visits to the supermarket, hydrotherapy, pat-a-dog scheme and luncheon clubs. A coffee morning was held on the day of the inspection to raise money for the amenities funds and relatives were involved in this. Service users were supported to exercise choice with regard to food, drink and activities. They were able to move freely around the home and to spend time in communal and private areas as they wished. Staff demonstrated their skilled and caring approach to service users and engaged them in a ball throwing activity, which generated a lot of laughter amongst service users. The activity provided them with an opportunity for exercise and positive feedback. Staff included all those who wished to be involved and provided support where necessary. Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 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): 16, 18 Concerns raised with the home are addressed appropriately. Systems are in place to ensure that service users are protected from abuse. EVIDENCE: A complaints log is maintained and the home’s complaints procedure is clearly displayed. One complaint received in March 2005 by the Commission for Social Care Inspection and investigated by the service provider was dealt with appropriately. The registered manager has introduced a system for recording any concerns raised and the record shows that these are addressed. Any concerns raised are also discussed with staff. A service user said he would speak to staff were he to be unhappy about anything, but that he had no complaints. An adult protection and whistle-blowing procedure is available. It is positive to note that further adult protection training has been arranged for November 2005. The home’s manager and staff have dealt appropriately with previous adult protection issues. The registered manager has also delivered training to staff at the home on rights and responsibilities, including anti-discriminatory practice. Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 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 is clean, pleasant and hygienic. EVIDENCE: The home is generally well maintained both internally and externally. A cleaning regime is in place and on the day of the inspection the home was clean, tidy and odour free. Some beds and bedding have been replaced, as have some curtains and light shades. Some bedrooms have been redecorated. The covering to some lounge chairs is worn and these should be repaired or replaced. Call points are available throughout the home, but call leads were not available at all points. When a service user, who was sat in one of the lounges and who required assistance, was asked how he would attract the attention of staff he said he would call out. But this is not a satisfactory system and alternative measures should be looked into which allows service users to attract the attention of staff without having to call out. Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 14 Work is ongoing to address outstanding fire safety issues. Until confirmation has been received that works have been completed to the satisfaction of the fire authority, the previous requirement is carried forward. The fire system is checked on a weekly basis. Staff are involved in fire drills and receive training in fire safety from the deputy manager who has received relevant training in this area. Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 15 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, 29 30 The numbers and skill mix of staff is suitable to meet the needs of current service users. Generally, the home’s recruitment processes support service users. Staff receive relevant training to ensure they are trained and competent to do their jobs. EVIDENCE: Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 16 Staff wear name badges including their photograph to help people to recognise them. At a minimum, there are five care staff including a senior carer on the morning and afternoon shifts and three wakeful night carers including a senior. The care manager’s hours are in addition to this. Ancillary staff includes housekeepers, cook and kitchen domestics and administrative support. The home is fully staffed at present. Staff demonstrated some of the skills necessary when working with older people with dementia. The care manager reported that NVQ training is ongoing at the home with seven staff having completed the award. The ratio of 50 of the workforce having an NVQ level 2 or equivalent qualification has not yet been achieved and a recommendation is carried forward. Relevant training is provided to staff. Examples of recent training are challenging behaviour, fire safety, movement and handling, food hygiene. New staff receive induction training and this also includes infection control and fire safety. Infection control training for remaining staff has yet to be arranged. Adult protection training has been arranged for November 2005. Staff spoke positively about training and gave examples of how it had influenced their care practice. Staff recruitment information was available and relevant checks had been carried out. However, although two references were available for one carer from non-care work positions, Anchor Homes had not sought a reference from a care provider who had recently, previously employed the person and who would have been able to comment on the person’s performance in the role of carer. A recommendation is made regarding this. Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 17 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, 38 The Commission has assessed the home’s manager as being fit to manage the care home. Systems are in place to ensure that the home is run in the best interests of service users and to ensure the health, safety and welfare of service users and staff. EVIDENCE: The Commission for Social Care Inspection has registered Jason Corrigan as being fit to manage the care home. He demonstrates a proactive approach to managing the home and to working with service users, staff, relatives and outside professionals. Mr Corrigan arranged for a local advocacy group to attend a recent staff meeting. And for Community Psychiatric Nurses to visit the home on a monthly basis so that they are available, on an informal basis, to discuss and Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 18 answer any questions that staff, relatives or service users may have about dementia care. Consultation about the services provided at Tolson Grange is currently taking place with relatives through questionnaires and comment forms. Service users who are able to comment are also included. On completion of the quality review, a copy of the report must be made available to service users and a copy supplied to the Commission. A requirement is made. A relatives’ meeting has been arranged for November 2005 and letters of invite have been sent out. Mr Corrigan spoke about wishing to involve relatives in the day-to-day life of the home. An amenities group has been set up to raise funds for service users’ activities and relatives are being encouraged to be involved in running the group. As noted in the section on Daily Life and Social Activities above, relatives were involved in the home’s coffee morning. Monthly visits by the registered provider required under The Care Homes Regulations 2001 also provide an opportunity for the provider to assess the quality of service provided by the home. It is of concern that these visits have not been taking place as required and reports are not being supplied to the Commission. It is noted that a visit had been made in the week prior to the unannounced inspection. A requirement is carried forward from the previous inspection. Health and safety systems are in place to promote the health and safety of service users and staff. A sample of service certification was satisfactory. Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 19 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 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X 3 X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X X 1 3 Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 20 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 OP3 Regulation 14(1)(d) Requirement Written confirmation must be provided to service users that, following assessment, the home can meet their needs. All of the service user’s identified needs must have a corresponding plan of care which details how those needs are to be met. Schedule 1 and 2 works identified in the fire officer’s report dated 01.10.04 must be completed and evidence of completion, agreed by the fire authority, must be supplied to the Commission. (Timescale of 01.04.05 not met). On completion of the home’s quality review, a copy of the report must be made available to service users and a copy supplied to the Commission. The registered provider must supply a copy of the report required under Regulation 26 of The Care Homes Regulations 2001 to the Commission. (Timescale of 18.03.05 not met) Timescale for action 03/11/05 2 OP7 15(1) 03/12/05 3 OP19 24(4) 03/12/05 4 OP33 24(2) 03/01/06 5 OP37 26(5) 10/11/05 Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 21 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. Daily reports on service users should clearly reflect delivery of the care plan and the outcomes for service users. The registered person should ensure that service users where able and/or their representative signs service user care plans. (Recommendation carried forward). Service users should have access to call bell leads for attracting the attention of staff. 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 by 31.12.05. (Recommendation carried forward). Where a person is employed to work in the home in a care position, where possible and appropriate, a reference should be obtained from a previous employer who employed the person in a care capacity. Evidence should be available for inspection that all staff working at the care home have received training in infection control. (Recommendation carried forward). The person carrying out visits under Regulation 26 should sign the report. (Recommendation carried forward). 2 3 4 5 OP7 OP7 OP22 OP26 6 OP28 7 OP29 8 9 OP30 OP37 Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 22 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 © 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 Tolson Grange DS0000026339.V256966.R01.S.doc Version 5.0 Page 23 - 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. 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