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Town Moor House Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 July 2018

The inspection took place on 21 June, 2018 and was unannounced, which meant that nobody at the service knew we would be visiting. At the last inspection in April 2016, the service was rated overall Good, but was rated Requires Improvement in responsive. At this inspection we found the service was rated overall Requires Improvement.

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

Town Moor House is a 28 bed home providing care and support to older people. The home also provides care and support to people living with dementia. The home is a converted older property near the centre of Doncaster.

At the time of our inspection the service had a registered manager. 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.

People told us they felt safe. Staff were knowledgeable regarding safeguarding and were aware of how to identify possible abuse and the correct procedures to record and report. Risks associated with people’s care had been identified and staff were knowledgeable on how to manage the risks but documentation was not always reviewed or updated when needs changed.

We observed that there were enough staff available to meet people’s needs in a timely way.

Medication systems were robust; however, we identified issues that meant these were not always followed by staff.

Accidents and incidents were monitored and the registered provider ensured lessons were learnt. However, the monitoring could be more detailed to ensure a thorough analysis.

The service was clean and had a maintenance programme. Some areas required attention however; these had been identified by the registered provider. We also found the environment did not always meet the needs of people living with dementia.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The management team were aware of who had an authorised Deprivation of Liberty Safeguards or if any conditions were attached. Consent to care and treatment was sought in line with current legislation. However, we identified that best interest decisions were not always considered.

Staff received training on a regular basis. Staff were knowledgeable about their role. People received a nutritious diet, although documentation for recording this could be improved. People had access to healthcare professionals and staff followed their advice.

We observed staff interacting in a positive way with people. People told us the staff were very kind and caring. Staff were observed to be kind and considerate, the interaction we saw was very respectful. People’s privacy and dignity was respected. However, staff did not always respect people when they were discussing care and treatment in communal areas.

People received care and support that met their needs. Staff were aware of people’s needs and preferences. However, the care delivery could be more individualised and person centred.

A range of activities took place. People told us about the activities that they took part in and told us they were very good. People told us they felt able to raise concerns and complaints and were listened to. The registered provider learned lessons from complaints received and took appropriate actions.

Audits were in place to ensure policy and procedures were followed. However, we found they had not identified all the areas for improvement and could be more detailed. The registered provider

Inspection areas

Safe

Requires improvement

Updated 27 July 2018

The service was not always safe.

People were safeguarded from the risk of abuse.

Risks associated with people’s care had been identified but care records were not always reviewed or updated

Systems were in place to manage medicines safely. However, these were not always followed.

There were enough staff available to ensure people’s needs were met in a timely way.

Effective

Requires improvement

Updated 27 July 2018

The service was not always effective.

Staff were knowledgeable about people’s needs and attended regular training to update their skills.

Care plans were in place to support people who lacked capacity. However, best interest decisions had not always been documented.

The environment could be improved to meet the needs of people living with dementia.

People were supported to maintain a balanced diet which met their needs and preferences. Although some documentation required improvement.

People had access to healthcare professionals when required, although from documentation it was not always clear if their advice was followed.

Caring

Requires improvement

Updated 27 July 2018

The service was not always caring.

Staff discussed confidential information in communal areas so peoples privacy was not always maintained.

Staff ensured people were treated with dignity and respect and their preferences were upheld.

We observed staff interacting with people who used the service and they were kind and caring.

People had opportunities to maintain relationships with their family and friends.

Responsive

Requires improvement

Updated 27 July 2018

The service was not always responsive.

People received personalised care that responded to their individual needs. However, documentation could have been more detailed and up to date.

A good range of appropriate activities were provided.

People were aware of the complaints procedure and felt able to raise concerns. People felt that staff would listen to them and resolve any issues.

Well-led

Requires improvement

Updated 27 July 2018

The service was well led, but systems required improving and embedding into practice.

The registered provider and registered manager were committed to ensure the service continued to improve.

Audits took place to ensure the service was maintaining quality. However, these were not always effective. The registered provider was implementing new systems to ensure this improved.

People were listened to and their views were sought.