Inspection on 19/10/05 for Bowlacre

This inspection was carried out on 19th 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

Bowlacre 25/06/07

Bowlacre 02/05/06

Bowlacre 21/04/05

Bowlacre 30/11/04

Bowlacre 06/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bowlacre Elson Drive, Stockport Road Gee Cross Hyde Tameside SK14 4EZ Lead Inspector Janet Ranson Unannounced Inspection 19th October 2005 09:30 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 Bowlacre DS0000005562.V259530.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. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bowlacre Address Elson Drive, Stockport Road Gee Cross Hyde Tameside SK14 4EZ 0161 368 2615 0161 368 6015 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) Bowlacre Home Anne Irwin Care Home 37 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (37), of places Physical disability over 65 years of age (4) Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users up to 37 OP up to 6 DE (E) and 4 PD (E) Date of last inspection 21st April 2005 Brief Description of the Service: Bowlacre is a large, detached building set back from the main road within its own grounds. The building has been extended and adapted over the years to provide accommodation for 37 older people with physical disabilities and dementia type conditions. The home is owned and managed by a voluntary housing association. The bedrooms are located over two floors. In total there are 33 single rooms, 31 of which have en-suite facilities, and a further two shared rooms, both with en-suites. On the ground floor there are two sitting rooms, one dining room and a large conservatory. Aids and adaptations are in place to meet the assessed needs of the service users. Bowlacre is located in a residential area of Gee Cross. The grounds are well maintained and fully accessible to the service users. Car parking is to the front of the property. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Bowlacre Home provides personal care to 37 residents over 65. The home is owned by a voluntary organisation and managed by committee; the chairman attends the home on a daily basis. This was an unannounced inspection carried out over eight hours in the presence of the acting manager. The chairman, who is also the registered person, was present during the inspection. The purpose of the inspection was to ascertain the quality of life for the residents, compliance with requirements made at the previous announced inspection in April 2005 and to investigate two serious incidents concerning the recent theft of medication. The inspector spoke both informally various members of staff and an interviewed by telephone. Certain process. Comment cards were left friends to complete. and formally with three residents, four NVQ assessor. A relative was also records were inspected as part of the for the residents and their relatives or The personnel and financial administration of the home is carried out by clerical staff. In addition to the clerical and care staff, the home employs a maintenance person, a gardener and a team of housekeepers and catering staff. What the service does well: Bowlacre provides a good level of training opportunities to all the staff. The residents are becoming to be more involved in their daily living choices. The meals are well presented with a good choice providing balance and nutriment. The home is well maintained and is set within pleasant gardens. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Bowlacre DS0000005562.V259530.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 Bowlacre DS0000005562.V259530.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): 1, 2, 3 & 4 Prospective residents now have the required information to make an informed choice of where to live and a contract providing the terms and conditions. Systems are in place to ensure individual needs are identified prior to admission. EVIDENCE: Requirements concerning the statement of purpose, service users guide and a contract between the resident and the home, have now been satisfactorily completed and made available to the residents. The acting manager described how she had reassessed a resident who had been admitted into the local hospital and was considered by the healthcare professionals to be fit for discharge back to Bowlacre. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 9 It was considered that the resident’s needs could continue to be met at Bowlacre. The resident’s family had been informed of the decision and the resident was expected to return on the day of the inspection. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 10 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 & 11 There was little improvement in the quality of care plans and risk assessments. The home’s medication administration practices are safe. EVIDENCE: Four care plans were examined as part of the inspection process. They included residents who had lived at the home for a long time and those recently admitted. The home uses a pre-printed care documentation system. Despite this issue being identified as deficient at the last inspection, there continues to be little improvement. Important information concerning the residents had failed to be obtained and documented and it was clear the care plans were not being completed in the correct manner. The system is unwieldy and does not lend itself to ease of use by the carers. The manager must take responsibility for the poor standard of recording. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 11 Regardless of the poor quality records, the residents were able to confirm that their needs are being met and, at discussion, the carers felt sure they were meeting individual residents’ needs. Staff felt the verbal communication they received at handover was adequate. A relative reported that the “home was well run and organised”. The district nursing service was meeting individual healthcare needs during the morning of the inspection. The acting manager interacted with the nurse in a professional manner. Recent incidents concerning the theft of medications had been reported to the Commission for Social Care Inspection in the required manner, and investigated by the home. It was unfortunate that the registered manager was not available and any papers associated with the investigation could not be located. It was understood that these matters had been reported to the Police. The manager had taken steps and had put safeguards in place in an effort to increase medication security. Four medical administration records were examined and found to be completed in a satisfactory manner. Storage was appropriate and all the senior staff responsible for the administration had received training. Practice was also observed during the day. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 12 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): 14 & 15 The residents and their representatives have opportunities to influence their daily life choices. EVIDENCE: The residents who spoke with the inspector explained there were meetings with the staff where discussions concerning the content of the menu, activities and trips out took place. The meetings are also open to relatives or the residents’ representatives. The chairman regularly produces a newsletter in an effort to keep everyone in touch with forthcoming events. The daily menu is written on a wipe clean board in the dining room. The main meal of the day is at lunchtime. The dining tables were nicely arranged and the meal well presented. One of the choices had been requested at a recent residents’ meeting. After the meal the residents voiced their satisfaction to the inspector and generally commented on the excellent quality of the meals. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 13 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 The home is failing to address the seriousness of complaints and ensuring the complaints system is complied with. EVIDENCE: A record of complaints was examined. The details were not adequately recorded to form an opinion on the outcome for the complainant or to show that the home’s complaints policy had been carried through. A relative who spoke with the inspector after the inspection stated he did not feel that complaints to the management and the committee were taken seriously or acted upon. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 14 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): 20, 23,25 & 26 Bowlacre is a well maintained home with good standards of safety, hygiene and cleanliness. EVIDENCE: Newly constructed ramps have been built at the front of the building. access to the garden has also been improved. The The communal facilities within the building are comfortable and it was evident that the residents were able to use all the areas in the home. The grounds are well tended and maintained to a high standard and very much appreciated by the residents. The residents confirmed their satisfaction with their accommodation. One person described how she had recently moved to another bedroom at her request. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 15 Bowlacre has a designated smoking area in the conservatory. A visitor stated he had complained that the smoke could enter the adjacent lounge and felt there should be a ban on visitors smoking within this area. He felt his complaint had not been properly addressed. The home was found to be very clean and pleasant there were no offensive odours noted. A housekeeper who spoke with the inspector was rightly proud of the home and of the high standards of hygiene. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 16 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 & 30 Bowlacre provides good training opportunities for staff at all levels. EVIDENCE: The home continues to be committed to the National Vocational Qualification (NVQ) system. Senior carers are involved at level 3 and with other carers at level 2. There is a financial incentive for those staff members who achieve the qualification. The manager should be commended for her ability to source additional training for the staff. Particularly worthy of note is the inclusion of the housekeepers in training in dementia awareness and the protection of vulnerable adults. The NVQ assessor was present at the home. She stated that the staff were very enthusiastic and were presenting good course work. Bowlacre DS0000005562.V259530.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, 32, 33, 36 & 37 The manager is continuing to fail to provide leadership and supervision. The home’s record keeping does not guarantee the residents’ welfare or best interests. EVIDENCE: The manager is yet to complete the NVQ level 4 (registered managers award) as required from the previous inspections. It is understood that there has been a problem with the training provider. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 18 At the last inspection there was a requirement that the purchased quality assurance system be put into operation. The acting manager described how she intended to carry this out. Whilst this action is applauded, it remains the responsibility of the registered manager to ensure the smooth operation of the home and to provide leadership and direction. The formal supervision system remains in place. It was disappointing to hear that the process of supervision has lapsed since the last inspection when the staff had received the appropriate training and were very enthusiastic. The general maintenance of the records required by legislation continues to be poor. In particular, the fire register where it would appear the last test on the fire precautions had been carried out in July 2005. The acting manager said the tests had been completed as required. As described elsewhere in this report, documentation regarding a recent investigation was unavailable and there has been little improvement in the care planning process. Bowlacre DS0000005562.V259530.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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X 3 X X 3 X 3 3 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X 2 1 X Bowlacre DS0000005562.V259530.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 OP11OP7 Regulation 15(1)(2) 12(2)(3) Requirement Timescale for action 01/04/06 2 OP16 3 OP31 4 OP33 The registered person must ensure that care plans are completed in sufficient detail to provide clear instructions to the carers on the action to be taken to fully meet the resident’s identified needs. (Previous timescale of 01/07/05 not met). 22(3)(4) The registered person must 17(2) ensure that all complaints are recorded and investigated in accordance with the home’s complaints policy. 9(1)(2)(b) The registered manager must ensure achievement of National Vocational Qualification level 4 (registered managers award) (Previous timescale of 30/04/05 not met). 24(1)(a) The registered person must (b)(2)(3) ensure the quality assurance system is implemented. (Previous timescale of 01/07/05 not met). 01/04/06 01/06/06 01/04/06 Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 21 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. 5 Standard OP37 Regulation Requirement Timescale for action 01/04/06 6 OP36 17(1) The registered person must 26(1) 5(a) ensure all records required by legislation are kept in good order well maintained and presented. The registered person must also ensure compliance with Regulation 26 of the Care Homes Regulations 2001, visits by the registered provider. (Previous timescale of 01/07/05 not met). 18(2) The registration person must ensure that staff receive supervision at least six times a year. 01/11/05 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 OP25 Good Practice Recommendations The registered person should ensure there is adequate ventilation to the designated smoking area to prevent the smoke from drifting into the lounge areas. Bowlacre DS0000005562.V259530.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Bowlacre DS0000005562.V259530.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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