Inspection on 30/08/05 for Townsend House

This inspection was carried out on 30th August 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

Townsend House 15/10/07

Townsend House 19/09/06

Townsend House 20/01/06

Townsend House 28/09/04

Townsend House 25/05/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE TOWNSEND HOUSE Bayswater Road Headington Oxford OX3 9NX Lead Inspector Jane Handscombe Unannounced 30 August 2005 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. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Townsend House Address Bayswater Road, Headington, Oxford OX3 9NX 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) 01865762232 01865 744681 The Orders of St John Care Trust Jeannnie Pyle Care Home 45 Category(ies) of Pasr or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (17), Learning disability over 65 years of age (3), Old age, not falling within any other category (45), Physical disability over 65 years of age (20) TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The total number of persons that may be accommodated at any one time must not exceed 45. Date of last inspection 25 May 2004 Brief Description of the Service: Townsend House is situated in Headington on the outskirts of the city of Oxford. It is a care home for 45 older people, formerly a County Council home and now the responsibility of The Orders of St John Care Trust. The two storey building has a lift and each room is linked to a call system to summon staff assistance when required. The care home provides single rooms with several lounge areas, one being designated for smoking. There is a communal dining room, an attractive conservatory room and pleasant accessible grounds with seating. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on 30th August 2005. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The visit involved speaking to residents to ascertain their views upon the care they receive at the home, staff members and the manager, viewing records held whilst also observing the day to day operations of the home. The home presented as one with a homely ‘family’ atmosphere, which was generally presented as clean, tidy and of very good décor. Residents were going about their daily activities in a calm relaxed atmosphere whilst staff were observed to provide care and support to the residents in a calm, unhurried manner and respecting their individuality, privacy and dignity at all times. Comments received from residents during the inspection include: ‘They are very good here’ ‘I feel very safe here’ ‘I am happy, quite happy’ ‘The staff are very good, nothing is too much trouble’ The inspector would like to thank the residents, staff and the owner for their warm welcome and their assistance during the inspection process. What the service does well: The home has a very friendly, caring inclusive atmosphere in which the residents feel confident that they are very well cared for, and their right to privacy and dignity is upheld at all times. The home ensures policies and procedures are followed, and stringent recruitment procedures and pre employment checks have been undertaken on all staff to safeguard the health, safety and welfare of the residents in their care. Special occasions and birthdays, are acknowledged and celebrated in the home. All residents and their family and friends are invited to join residents in their celebrations. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: There are a number of things that Townsend House could do better which have been addressed within this report. Service users’/representatives’ signatures should be gained when undertaking care needs assessments/reviews to evidence that the service users have taken part in the process and are aware of the content. Likewise a signature of the person undertaking the assessment must be gained, as must the date that it was undertaken, to evidence the assessment/review has been undertaken by a person qualified to do so. Care must be taken to ensure that the undertaken assessments, accurately reflect any risks that may be present to both the resident and care staff. Information given to residents should be completed in full and contain all relevant details. With regard to the complaints procedure, this should contain all contact details in order to inform the residents of the various options available to them and thus allow them to make an informed choice. Please contact the provider for advice of actions taken in response to this TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 and 5 Prospective users of the service, relatives and other interested parties are provided with comprehensive information about the home and the services they are able to offer, along with introductory visits enabling them to make an informed decision when deciding upon whether the home is suitable for their needs. All prospective service users undergo an assessment of needs to ensure that both parties are confident that these assessed needs can be met at Townsend House. Service user involvement was not evidenced in all cases. EVIDENCE: The home provides a Statement of Purpose and Service Users Guide to all service users. All prospective service users are supplied with the Order of St John Care Trust brochure, which includes the Trust’s ethos of care, newsletter and inserts specific to the home. The brochure contains a good standard of information in an accessible format. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 10 Prospective service users undergo an assessment of needs, by a person qualified to undertake such assessments in order that both parties are able to ascertain as to whether these needs can be met at Townsend House. Prospective users of the service are given the opportunity to visit the home, fellow residents, care staff who will be providing the care and to view the facilities and rooms available at the home, in order that they can gain a ‘feel’ of the home and make an informed choice about where to live. Four residents’ files containing their original assessment were viewed, and whilst the inspector was informed that all assessments are undertaken with the prospective resident and/or their representative, three of the files did not contain a signature to evidence they had been involved in the process. One of these was rectified, in that the resident did sign his during the course of the inspection. A requirement has been made within the report to address this issue. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 11 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 and 9 Residents’ health, personal and social care needs are set out in a plan of care, although those seen on the day of inspection were found to be incomplete and lacked important information. Residents who wish to remain responsible for their own medication are encouraged to do so within a risk management procedure EVIDENCE: During the inspection, the inspector viewed four residents’ files in order to case track, which were generally found to be incomplete. Two files failed to contain a photograph of the resident, one of which was corrected and added during the inspection. It was found, in all 4 cases, that care plans were not always signed by the resident or their representative to evidence that the resident was involved in the process. Furthermore, two of the four care plans failed to contain the signature of the person who had undertaken the assessment to evidence that they were qualified to do so. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 12 One file contained a moving and handling assessment, which failed to reflect that the resident was a wheelchair user and their pressure sore risk assessment was found to be undated. A requirement has been made within this report informing that all information within care plans is completed, since this was not evident, and has been signed appropriately with the service user and/or a representative. A further requirement has been made within this report to ensure that all care plans be reviewed and updated. Residents who wish to maintain responsibility for their own medication are protected by the home’s policies and procedures for dealing with medication. Locked facilities are provided and the home will assist in ordering prescriptions for individuals requiring their assistance. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 13 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 and 14 The home promotes independence in daily life and social activities. Residents are encouraged and supported to maintain contact with the local community and family and friends. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 14 EVIDENCE: There are few routines at Townsend House and these are centred around meals and mealtimes. Service users are encouraged to follow their social, cultural, religious and recreational interests and needs. A hairdresser visits the home twice a week and residents are able to make appointments if required. Likewise, a visiting minister provides Holy Communion weekly for those who desire and there are links with the local Church of England St Mary’s church. A range of activities offered at the home were seen to be displayed on notice boards within the home to which residents can attend if required. The activities co-ordinator ensures to spend one to one time with residents who do not wish to attend group activities, and makes every effort to ensure residents find the activities enjoyable, stimulating and meets their needs. The home is interviewing for an activities co-ordinator to replace the present member of staff who is to continue in her studies. Two care leaders have undertaken training in seated exercise and offer gentle exercises to those residents who require. Residents are encouraged and supported to maintain contact with family and friends, and are supported to go out and visit family and friends when required. Visitors are made to feel very welcome and may visit their family members/friends at any time. The home has a comfort amenity fund, whose committee is made up of staff, residents and family members, which provides for outings and entertainment. Residents have enjoyed a recent holiday to Minehead and a residents, relatives and friends barbeque both of which were enjoyed by all. Residents were complimentary about the meals they receive at Townsend House and were observed to be enjoying a lunch consisting of Piquant Pork Chops or Lamb Hot Pot with creamed potatoes, cabbage and broad beans, followed by a choice of rice pudding with jam or a choice from the sweet trolley. The food looked very appealing, was well presented and portions were of a decent size. One resident informed the inspector that ‘the food is excellent, they have a very good chef’ which appeared to be the general consensus amongst the residents. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 15 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, 17 and 18 There is a complaints procedure, which is on view in the home for residents and visitors to the home to access if the need arises and can also be accessed in the Service Users Guide, although there are omissions which need to be addressed. EVIDENCE: The complaints procedure is displayed on notice boards within the home for residents, their families and visitors to access should the need arise. The policy and procedure may also be found in the Service Users Guide, although this was found to be incomplete; contact details of both the Commission for Social Care Inspection and the County Director need to be added to allow residents to make an informed choice on who to take a complaint to. An open culture is apparent in the home, and those spoken to during the inspection informed the inspector that they felt confident in bringing any concerns, or making constructive suggestions, to the manager or that of the residents meeting which is held every other month and felt that they would be dealt with both seriously and appropriately. All residents are on the electoral role and are supported to take part in local and general elections either by postal vote or in person at the local polling station. Details of an independent advocacy service are displayed on notice boards in the home and details may be found in the service users guide. The manager and staff are happy to help residents access the service if required to do so. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 16 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) 22,23, 24, 25 and 26 The home provides comfortable surroundings, which are equipped to meet the residents differing needs. EVIDENCE: On the day of the inspection, the home was clean and tidy with a homely atmosphere. The manager informed the inspector that the home encourages residents to bring small items of furniture and memorabilia to personalise their rooms to their own liking, which was evident on touring the home. Whenever a room becomes available for new residents it is redecorated, and individual involvement in redecoration of rooms is encouraged. Residents are provided with a key to their room if they wish allowing them privacy, and lockable storage is also provided. Each bedroom has an alarm near to the bed in order that assistance may be sought when required. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 17 Residents spoken to on the day informed the inspector that they were very happy with their rooms and found them to suit their needs. Some redecoration has recently taken place to include: the repainting of all doorways throughout the home, four new carpets have been laid in residents’ bedrooms with a further two bedrooms are awaiting new carpets. All parts of the home are accessible to the service users, with the use of grab rails and a lift to facilitate mobility around the home. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 18 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, and 29 Townsend House operates a recruitment procedure that ensures the protection of the residents in their care. Whilst the staffing levels meet the requirement they do not appear to allow for quality time to be spent with residents. EVIDENCE: There are stringent policies and procedures in place with regard to the recruitment of staff and all relevant checks and induction training are adhered to, thereby protecting and supporting the residents in their care. The inspector spoke to care staff during the inspection, who informed the inspector that they felt they were just able to carry out the care needs of the residents, but they would like to be able to offer more quality time to individuals. Sometimes they find that they are very pushed to manage the basic care requirements. Further comments included that of the staff breaks, which the inspector discussed with both the manager of the home and the care services manager visiting the home on the day. It was agreed that the manager would address these issues and discuss them at the next staff meeting. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 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 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) 33, 37 and 38 Townsend House is a well managed home, run in the best interests of the residents, using the service. Safeguards are in place to protect their health, safety and welfare. EVIDENCE: The Registered Manager has undergone registration with the CSCI, deeming her a fit person to manage the home. She has many years of experience of working with older people and has more than two years management experience. There are clear lines of accountability within the home and within The Orders of St John Care Trust. Residents and members of staff reported that the manager runs the home in an open, positive, inclusive way and they would have no worries approaching her if they had any concerns and were confident that they would be listened to and dealt with appropriately. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 20 Regular residents’ meetings take place, in which open discussions and suggestions take place around issues regarding the home, the care provided, meal provision, entertainment etc and any points that the residents would like placed on the agenda. These meetings are minuted and easily accessed via the notice boards within the home. TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION x x x 3 3 3 3 x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 x x x 3 x x x 3 3 TOWNSEND HOUSE H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 22 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 OP3 and OP7 Regulation 14 Requirement The registered manager must ensure assessment of needs and reviews of care are dated and gain the service users/advocate signature to evidence their part in the process and contain the signature of the assessor A photograph of each resident must be held on file All care plans to be reviewed and updated and transferred to the new format. The complaints procedure must include the name, address and telephone number of the Commission Timescale for action Immediate and henceforth 2. 3. 4. OP7 OP7 16 17(1)(a) Schedule 3 Immediate and henceforth September 30th 2005 September 30th 2005 22(6)(a) 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 27 Good Practice Recommendations It is reccommended that the staffing levels and deployment of staff be looked at in relation to the dependency needs of the residents. H57-H08 S13161 Townsend V246757 300805 Stage 4.doc Version 1.30 Page 23 TOWNSEND HOUSE Commission for Social Care Inspection Burgner House Cascade Way Oxford Business Park South Cowley, Oxford OX4 2SU 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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