Archived: Thomas Tawell House

We found the following examples of good practice.

The staff worked together as a team, to support the people living at the home, and their work colleagues. This was particularly important while working during the outbreak at the home.

Where people needed to self-isolate, one to one activities and regular interaction with staff was put in place to prevent the risk of social isolation.

Arrangements were in place to prevent the spread of infection, for example processes were in place to store used laundry, cutlery and crockery when supporting people that had tested positive for COVID-19.

Thomas Tawell House accommodates up to 37 people in one adapted building. At the time of the inspection there were 23 people living at the service, some of whom were living with a sight impairment.

People’s experience of using this service and what we found

Staff understood the risks to people and the measures in place to keep them safe. Systems were in place to manage people's medicines safely and to reduce the risks associated with the spread of infection.

Sufficient numbers of staff were employed to meet people's needs. Staff received training which gave them the necessary skills and knowledge to carry out their roles and meet people’s needs.

Systems ensured that people's risks were well managed, and lessons were learnt when things went wrong. There was an open culture within the service. People and staff could approach the manager, who acted on concerns raised to make improvements to people's care. A relative told us, “I have no issues at all with the care, they look after [relative] very well. I have no issues with the home at all, they know me, and I know most of the staff too. Staff treat [relative] really well and they are always caring and helpful. They always cater to [relative’s] whims and they understand their every need.”

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 21 May 2019)

Why we inspected

We received concerns in relation to the management of medicines. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well led sections of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has remained good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Thomas Tawell House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Thomas Tawell House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Thomas Tawell house is a care home supporting people living with visual impairments. The home was designed to support the independence of people living there. The home was a large one-story building with communal areas to allow people opportunity to have varied spaces in which they could relax, dine, undertake activities and even host events.

The home was registered to support 37 people, at the time of the inspection there were 24 people living in the home. Following the last inspection, the provider had taken the decision not to admit any further people to the home until improvements had been made. Shortly before this inspection new people had begun to be placed at the home.

Thomas Tawell had a registered manager who had been in post for approximately six months. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection we found six regulations to be in breach of the Health and Social Care Act (Regulated Activities) 2014. The home was found to be inadequate in the key questions of safe, responsive and well led and to require improvement in the key questions of effective and caring. The home was rated as inadequate overall. Since the last inspection there has been a change in the management structure of the home with a newly appointed registered manager and deputy in place. The nominated individual has also taken on a more proactive role in ensuring the service improved. The provider had recruited a consultancy company who had supported the service and had introduced basic and emergency plans including risk assessment and care planning to ensure people were kept safe.

Since the introduction of the new registered manager these were to develop and become a more comprehensive assessment tool which in turn would feed into more person-centred care plans. Work had begun to put this in place. We found the new management team including senior managers and the board members motivated and committed to continually drive improvement at the home.

Previous breaches had been found in regulations associated with staff and we had concerns about both the number of available staff and the training and support staff had received. We had concerns around how risks were assessed and mitigated and how restrictive practice had been assessed for people who lacked capacity. We found breaches in the regulation associated with person centred care and found people were not involved as they should be with deciding their care. We found their preferences had not been met once they had moved into the home. We also found a lack of dedicated and appropriate activities. We had concerns that complaints procedures were not accessible to people and complaints had not been handled appropriately or recorded. Lastly, we had concerns around how the provider had monitored the service delivered and the accuracy of any monitoring undertaken as it had not been effective at identifying concerns.

A consistent approach to service improvement had been adopted since the last inspection. A comprehensive action plan had been provided to the Care Quality Commission following the last inspection and we were given an up to date one at the start of the inspection This showed us ongoing systems were in place to identify, discuss and action any concerns or issues. The new registered manager had come into post after the initial support of the consultancy company ensured standards did not continue to worsen. This immediate and ongoing approach to take action to address concerns, had been sustained and had improved provision. This inspection found the provider had met all the identified breaches of the last inspection in November 2017.

As part of this inspection, we have made two recommendations to support the continued improvement of new systems and procedures as they were developing. We have recommended, people’s care needs and associated risks were more frequently reviewed and care planning and assessment tools become more inclusive. The registered manager had taken steps to address this by the end of the inspection. The second recommendation has been given to ensure that the current system of monitoring and audit continued to develop and allow any analysis to identify themes and trends. This in turn would focus ongoing development where it was most needed.

This inspection found there were enough staff on duty, at all times. Staff had been safely recruited and were motivated and supported to deliver good quality care and support. People living in the home told us the support they received was appropriate and met their needs. People’s nutritional and hydration needs were met with steps taken to provide additional support as required.

People were supported with their mobility and appropriate equipment and support was provided as required. Where people lacked the capacity the principles of the Mental Capacity Act were followed and best interest decisions were made to ensure appropriate consent was provided. Those living with capacity were involved and agreed with the development and changing of care plans used to support them. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

Medicines were managed and administered safely and people told us they felt their preferences were respected and their health and wellbeing was promoted. Where people had complained these had been managed and successful outcomes had been provided. People were given choices and a programme of specific and appropriate activities were provided.

Staff who worked directly with people in the home showed us personable relationships had begun to embed and it was clear they considered people’s needs throughout their day.

We saw risks had been assessed of the environment and all health and safety aspects of the service had been considered and risks managed. This included professional testing of equipment and ongoing monitoring of the service provided.

Meetings were held with both staff, people living in the home and relatives and everyone we spoke with told us they were kept informed and felt involved in decisions made in how the home was run. There was a system of audit and quality assurance that gave the management team information they needed to drive improvement in provision at the home.

At our last inspection on 20 and 21 September 2016, we found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found there were not sufficient systems in place for assessing, monitoring and improving the quality of the service provided. Improvements were needed to develop risk assessments in relation to people’s welfare. Records relating to people’s care were not detailed.

At this inspection, we found the service had further deteriorated. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection for the key question, ‘is the service responsive?’ we found the service was not always responsive to people's individual needs and preferences. The staff interactions were limited to focus on tasks rather than conversational and individual. There was a survey in place for people to give feedback on the service. We found that where people requested something to be altered, this was not always considered. The care records were not always detailed and individualised. We saw in some people's care records that they had variable continence. There was no further information, risk assessment or guidance about how best to support them. Where some people had a catheter in situ, there were no risk assessments in place concerning potential problems with them. Visiting agency staff or new staff did not always have clear, concise guidance to follow about people's care within the records.

At this inspection, we found the service had deteriorated resulting in six breaches of Regulation.

Thomas Tawell House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Thomas Tawell House accommodates 37 people in one adapted building. There were 29 people living in the home on the day of our inspection. The home supported people who were over 65 years of age, some of whom were living with sensory impairment.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated regulations. The CEO visited the service on the second day and third day of our visit at the request of the inspector.

Although the provider had systems in place to protect people from harm, we found these were not always effective. The majority of staff were trained in safeguarding adults yet the training was not always implemented in practice whilst supporting people. Staff told us they were aware of their responsibility to keep people safe however, they failed to identify some of the practices within the home which were abusive and breached people's rights to receive safe, respectful and dignified care. At the time of our visit, we requested the registered manager to complete a safeguarding referral to Norfolk local authority safeguarding team reporting our findings. The registered manager told us she did not know how to do this and we were given assurances from the CEO this would be done without delay. Evidence of this was seen before the end of our third day.

Risks to people's health and wellbeing were not appropriately assessed and reviewed. Care plans were not sufficiently detailed to provide an accurate description of people's care and support needs. Our concerns also involved the lack of intervention and reporting of visiting medical professionals, we shared these concerns with the primary medical services within the Commission who monitor and inspect General Practitioner [GP] practices. Those concerns have since been shared with Norfolk Clinical Commissioning Group [CCG].

Whilst staff were safely recruited there were insufficient staffing levels to support people's needs and people did not always receive care and support when required.

The registered manager could not demonstrate lessons learned and improvements made when things go wrong. The registered manager although demonstrated understanding of the Duty of Candour they were unable to explain their responsibilities in relation to it. Services are required to comply with the duty of candour regulation. The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' in relation to care and treatment. It also sets out some specific requirements that services must follow when things go wrong with care and treatment. We found this had affected one person. However, the CEO who had commenced with Norfolk & Norwich Association for the Blind (NNAB) in August 2017 had identified they needed to respond to the person impacted before we spoke with them. The CEO demonstrated sound knowledge of the duty of candour. The CEO shared with us their lessons learnt and improvement plan from our last visit in September 2016 identifying where improvements were needed. However, this was in its early stages and there had not been enough time since the CEO commenced and our visit for those areas to be explored properly with the registered manager.

The majority of the staff had completed training on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). However, we identified one person whose rights had not have been protected because the registered manager had not assessed their capacity to consent to receiving care in bed and had not considered whether they had their liberty deprived unlawfully. This had resulted in the person’s human rights also being impacted.

We identified gaps in training provided to staff. In spite of staff's best efforts and hard work to provide care in a supportive and friendly way, they lacked experience and training. All people living at the home had a sensory impairment and although staff had received training in regards to this when they first commenced employment, the training was not refreshed or revisited. We found some people lived with epilepsy, diabetes and some people had a catheter in situ, however, some staff had never completed training specific to those needs and others required an updated course. Some staff had received an appraisal of their work performance and most had received regular support and supervision. However, this had not always been effective in identifying inconsistencies in staff knowledge and practice.

Although people were treated in a caring and respectful manner, staff did not always engage with people when given the opportunity. People, who used the service, or their representatives, were not always encouraged to contribute to the planning of their care. We found that people’s privacy, dignity and independence were not always respected and promoted.

People did not receive person centred care as the care records did not give adequate information required for individualised care. We received mixed views on activities available. Some people told us that they were not given the opportunity to choose the way that their individual and group activities would be delivered. Other people told us although they were given opportunities to discuss activities their suggestions were not always met. We found there were few opportunities to engage in activities and people were seen sitting in the lounges or their bedroom with no meaningful activity or positive interaction taking place. Although processes were in place to deal with people's complaints and concerns if received, we were not satisfied the registered manager operated an effective accessible system for identifying complaints. There had been no documented complaints since 2013.

There was no shared understanding of the service’s vision and values and a culture of task-centred instead of person-centred care was embedded. The management of the service was inconsistent and lacked continuity. Systems in the service that were meant to monitor and identify improvements were not effective and records were not always maintained and completed in full. This lack of effective governance led to all people not receiving safe and consistent care. The care plans for people using the service were incomplete or did not contain up to date and regularly reviewed information. This meant staff was not able to perform their duties efficiently.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely. The home was clean and tidy throughout, routinely maintained and monitored by the provider. There was a varied and nutritious menu where people could make choices. Steps were taken to ensure people had adequate food and drink. People's health care needs were assessed, monitored and recorded. People had regular contact with health care professionals. We looked at documentation related to staff handovers. These recorded how people were supported to live healthier lives. They included appointments with healthcare professionals, feedback from healthcare professionals and action plans for staff to follow. The environment of the home was appropriate for people who were living with sensory impairment. The home was well maintained, decorated and furnished in a style suitable for the people who used the service.

At the time of our visit, the registered manager, CEO and board of trustee’

Thomas Tawell House is a residential care home which supports older people living with sensory impairment, for a maximum of 37 people. There were 35 people living in the home when we inspected. All of the people living there were visually impaired.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a registered manager who had been in post for several years.

Staff were trained in safeguarding and were aware of who to report any concerns to, and people felt safe living in the home. There were risks assessments in place for people with regards to their physical safety, and these provided guidance to staff on how to safely support them.

The home was making improvements to the recording around some medicines. Medicines were administered by staff who were trained to do so, and some people were supported to take their own medicines.

The home had safe recruitment practices in place so that only staff who were deemed suitable could work there. There were enough staff to keep people safe.

People felt that staff were competent in their roles. Staff had received training relevant to their role and felt confident. There was an induction procedure in place, which helped to train new staff. Staff asked people for their permission before delivering care.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Although staff did not always have training in these areas, we found that they were following the principles of the MCA. We have made a recommendation around training with regards to people’s mental capacity.

People were supported to eat a sufficient amount of food with a good choice of meals. There were drinks available at various intervals throughout the day, and people had drinks in their rooms.

Staff were compassionate towards people, and they encouraged people to be independent where they were able. They encouraged privacy when carrying out personal care with people. Staff supported people to maintain relationships with loved ones and involve them in their care. We did observe that there were some practices in place which did not always promote people’s dignity.

Although staff were cheerful and kind to people, the interactions were task-led. People were not always supported to participate in social events or activities which followed their interests. People did not always receive support to engage with others and follow their interests and hobbies.

Care records did not always contain clear detail and guidance about each individual’s life, preferences, and personal health needs. This meant that staff did not always have consistent guidance about how to support people effectively.

Although people we spoke with felt that they were involved in aspects of their care, there were some decisions that were not supported. This included bath and meal times. We spoke with the registered manager about this and they said they would review flexibility of the service.

There were not sufficient auditing systems in place to assess, monitor and improve the service. We found that the registered manager had not picked up on areas that required improvement, including monitoring staff competency, checking health and safety and medicines administration.

You can see what action we told the provider to take at the back of the full version of the report.

Care plans showed that people were involved in making decisions about how they wished to be supported and were regularly asked what they would like to do. Some of the information in people's care records was limited but staff were observed giving individual and personalised care.

There were choices from the menu at meal times and all of the people we spoke with said they enjoyed the food. Nutritional assessments had been done and there was evidence that people's nutritional needs had been met.

People using the service told us that they felt safe and had no concerns. We noted that the premises and environment promoted people's safety and security.

We saw that there were enough suitably trained and experienced staff to meet the needs of people using the service, although some people told us that they wished the carers had more time to speak with them.

The service had various methods that were used to ensure the quality of the service was monitored and audited. Meetings, reviews and audits were in place and records were available.

In total, we spoke with seven people using this service who all told us that they were very happy living at the home. One person told us 'I feel extremely lucky to be here, you hear of all these bad places on the television, I wish they would do a show about the good homes and we could show them how it's done'. Another person commented 'I am very well cared for, I could not ask for a better environment and to be with people that understand me'. A third person told us 'it's a wonderful place to live'.

Appropriate arrangements were in place in relation to obtaining and disposing of people's medication. We spoke with a member of staff, responsible for medication, who told us that medication for people living at the home was received on a four weekly basis from their nominated pharmacy.

We spoke with two members of staff who all told us that they were happy working at Thomas Tawell House, felt completely supported by their managers and confident in raising concerns should they need.

Records were well kept and secured safely.