Inspection on 02/05/06 for Bowlacre

This inspection was carried out on 2nd May 2006.

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 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 19/10/05

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 2nd May 2006 09:00 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.V289946.R01.S.doc Version 5.1 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.V289946.R01.S.doc Version 5.1 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 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.V289946.R01.S.doc Version 5.1 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 19th October 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.V289946.R01.S.doc Version 5.1 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 key inspection carried out over seven hours. The acting manager and chair of the committee were present throughout the inspection and the vice chairman attended for the feed back at the end of the day. In addition to clerical and care staff, the home employs a maintenance person, a gardener, a team of housekeepers and catering staff. The inspection process involved examination of certain records and files and a tour of the building. The inspector also observed care practices, interviewed residents and visitors and checked compliance with the requirement made at the previous inspection. What the service does well: What has improved since the last inspection? Improvements have been made to the general organisation within the office, which has had a history of disorderliness. Care files and other records required by legislation are now to hand and are maintained in good order. The new manager has addressed low staff moral that was noted at the previous inspection. Staff reported an improvement in the general atmosphere and stated their confidence in the management team. The new manager has commenced with the registration process. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 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. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 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.V289946.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the required information to make an informed choice of where to live and a contract providing the terms and conditions. Standard 6 intermediate care is not provided at Bowlacre. EVIDENCE: In the course of this inspection 4 files including long-standing residents and those of recently admitted people were examined. They all included an assessment of need carried out by either the Social Services department or the National Health Service. It was evident from the information contained within the assessments that the skills and numbers of staff at the home could meet the identified needs. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 9 The manager stated that she usually visited the prospective resident prior to their admission to introduce herself, describe the service and confirm the home can meet their needs. The residents who spoke with the inspector were not able to recall the process of assessment. Two visitors confirmed to the inspector that they had been involved in the assessment process and were aware of the homes statement of purpose and service users guide. Two people had recently been admitted during the night from the accident and emergency department of the local hospital. The manager had ensured the two residents had assessments and involvement from the social service department within a few days of their admission. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of care but greater supervision is required in order that the care planning system can be effective in documenting the residents identified needs. EVIDENCE: This home has had history of chaotic and disorganised record keeping under the previous manager. It was pleasing to observe that all the records were now maintained in an orderly manner. It was obvious that a great deal of reorganising and sorting out had been completed within the office area resulting in a more professional impression of the service. Four care plans were examined as part of the tracking exercise, including residents who had lived at the home for some time and those who had been recently admitted. The home was now using a pre printed document, which is part of a quality assurance package. The care plans have replaced a system that was unwieldy and was not “user friendly” as observed at the previous inspection when a requirement to improve this area was made. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 11 The replacement care plans are pre printed and contain prompts for the writer to complete; they are a vast improvement on the previous system. It is unfortunate therefore that they had failed to be completed correctly with areas within the plans that had not been addressed or had been ignored. This situation was apparent both in the plans that had been transferred from the previous system and those that had been completed for newly admitted residents. It is recommended that the registered person should seek training in care planning for the senior staff. An area of good practice noted and commented on by two visitors was the inclusion of the family in completing the resident’s social history. This forms part of the residents file and provides background and greater understanding for the carers. It was evident from the reports within the plans that routine and specialist health care is sought for the residents; dates of general practitioner, podiatrist, optician and dental examinations were all recorded. In addition residents were observed wearing glasses, dentures and hearing aids. During the inspection a doctor had been requested to visit a resident and the community nurse was attending to those resident’s with identified health care needs. A resident collapsed in the dining room whilst waiting for lunch. With minimum fuss the resident’s state was assessed and an emergency ambulance was requested. A carer volunteered to escort the resident to the hospital and the resident’s family was advised of the situation. The incident was managed in a very professional manner by all involved. Two visitors confirmed to the inspector that they felt they were still involved in the resident’s care and as illustrated above, were informed of any changes. The residents who spoke with the inspector were not aware of the care planning process or of the regular reviews of care. From observation of staff practice it was apparent that the residents were treated with great respect, visitors also felt this to be the case. The residents were appropriately dressed and clean. They also appeared to be comfortable and well cared for, those residents who spoke with the inspector said they felt comfortable and “the staff were all very good”. Four medication administration records (MAR) were examined and found to be completed in the approved manner. Medication storage was appropriate and all the senior staff responsible for the administration had received training. Since the previous inspection there had been a change in the contracting pharmacist. It was reported by the senior staff that the pharmacist provided them with a good service and support when required. The policy and actions concerning residents who want to self medicate was satisfactory. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are enabled to live a fulfilled life and are provided with a balanced and nutritional menu. EVIDENCE: A senior member of staff is responsible for the programme of activities. A record is retained of the activities and entertainment within the home and of trips to the theatre and garden centre. There were two jigsaws being completed in the lounge and newspapers and magazines in evidence. There are plans to celebrate Bowlacre’s fiftieth anniversary in the summer. Meetings with the residents and their representatives, where discussions concerning the content of the menu, activities and trips out take place and ensure people can contribute to the general running of the home. The chairman regularly produces a newsletter in an effort to keep everyone in touch with forthcoming events. It is very interesting and detailed and considered to be good practice. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 13 Those visitors who spoke with the inspector confirmed they could visit at any time and were made to feel welcome. They liked the informal atmosphere within the home and one person said they could speak with the senior staff if she had a problem concerning the care of her relative. The daily menu is written on a wipe clean board in the dining room. During the day both the meals (lunch and tea) along with the options were as described on the board. It was confirmed that the main meal of the day is at lunchtime. The dining tables were arranged for groups of four people and the meals were observed to be nicely served and well presented. After the meal the residents voiced their satisfaction to the inspector and generally commented on the excellent quality of the meals. One resident said that the meals are very good and commented on their increase in weight. The chef is knowledgeable and is able to provide for the resident’s various likes, dislikes and dietary requirements. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints procedure and staff training provides protection to the residents. EVIDENCE: There was a concern identified at the previous inspection by a visitor who maintained his complaint had failed to be addressed. During the course of this inspection two visitors to the home were asked if they had had to make a complaint. One relative said she would “refer to the homes literature”, (the service user’s guide to be found in each bedroom). Both visitors said they would have no hesitation in speaking to the manager or a member of the committee. Those residents who spoke with the inspector were not aware of the written complaints procedure but said they would speak either to their family or to a member of staff. The stated expectation of the visitors and residents was that their complaint would be taken seriously and acted upon. One Protection of Vulnerable Adults (POVA) investigation had taken place in line with the local protocols. Satisfactory strategies have been instigated to ensure the residents safety. The appropriate training to protect vulnerable adults has been undertaken by the senior staff and was provided by the local authority. The training enables them to “cascade” the training to the individual teams. Through interview a Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 15 member of staff demonstrated to the inspector her understanding of the principles of POVA. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 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 the following standard(s): 19, 20 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bowlacre provides the residents with a safe, warm, welcoming home. EVIDENCE: The committee chairman is addressing the lack of long-term investment into the homes infrastructure. Problems have been experienced with the electric wiring and the passenger lift due mainly to the systems age. It is understood that a replacement (larger) motor has been installed in the lift although it is recognised this is a stopgap measure. Plans have been drawn up and estimates received for a replacement lift. The chairman of the committee continues to “shop around” for the best deals in utility services. Light bulbs have been replaced with low energy and there has been an improved telephone system install. This allows the resident’s to use the phone in the privacy of their own rooms and at a lower cost. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 17 Likewise contracts with suppliers have been renegotiated to the benefit of the home. The inspector made a tour of the building. 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. Visitors to the home confirmed that Bowlacre was always clean and free from odours. One of them said it was the lack of odour in the home that confirmed her relative would be happy to live there. The resident’s accommodation had a lived in feel with many rooms nicely personalised. A visitor said she intended to furnish her relatives room once they had been confirmed as a permanent resident. Assisted baths and toilets are located over the two floors. The gardens to the front and rear of the building are particularly inviting. They are maintained to a very high standard and used in the better weather. There is level access directly from the conservatory. A vegetable plot is located to the side of the rear garden. The fresh seasonable vegetables are used in the homes kitchens. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 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 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, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff meet with the residents identified needs. EVIDENCE: The rota was examined as part of the inspection process. It documents the numbers of carers, housekeepers and catering staff on duty at any one time. Judging from this information and from observation on the day it was apparent that there was enough carers to meet the resident’s identified needs. The cleanliness of the home bore evidence there were enough housekeepers and the kitchen had dedicated chef and assistance every day. Two senior staff are on duty each day in addition to the manager who is supernumerary. The resident’s and their visitors confirmed they thought the staffing levels were satisfactory. A resident said, “They are all good girls.” A further resident said they are all “very good and attentive.” 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 and the newly appointed manager has enrolled on the level 4 as required. There is a financial incentive for those staff members who achieve the qualification. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 19 Historically the home had an over dependency on agency workers. The manager confirmed there had only used agency staff at Christmas and were now fully staffed. Carers who had worked at Bowlacre under the previous management had been reappointed after appropriate checks had been undertaken. At interview carers confirmed their confidence in the new manager and felt that they were now working better together than had previously been the case. The previous manager had a muddled and chaotic style and this remained apparent when the contents of two staff files were examined. One file demonstrated poor recruitment practice in that the applicant’s previous employment history was incomplete and there were anomalies with regard to statutory checks. The further file contained the appropriately completed documents and there was evidence that satisfactory references and checks had been carried out. A team leader said that formal supervision was back on track and the mandatory training was being up dated. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 20 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, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are good systems to ensure the health, safety and welfare of the residents, visitors and staff. The home has failed to instigate a quality assurance system, which would provide the resident’s with the opportunity to contribute towards the service. EVIDENCE: The newly appointed manager has commenced the process of registration with the Commission for Social Care Inspection as required. She was a team leader under the previous manager. She has made a good start at rebuilding rapport with healthcare professionals, social workers and other stakeholders. The staff state that Bowlacre is a good place to work and confirm their confidence in the manager’s abilities. She also has the total support of the chairman of the committee. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 21 There remains a requirement for the registered person to comply with the requirements of regulation 26 visits by the registered person and for a quality assurance system to be implemented and advice was given concerning these issues. The home facilitates the services of an independent financial advisor who visits the home on a monthly basis. Some personal allowances were retained in the office for safekeeping. Appropriate records with receipts of expenditure were maintained and examined. The chairman confirmed the insurance cover was in place and was adequate to meet the amounts held. Policies and procedures are in place to ensure the health, safety and welfare of the residents, the visitors to the home and the staff. Aids and adaptations are provided to enable the residents to move safely around the home. The fire precautions and signage were found to be in order. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 23 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 OP7 Regulation 15(1)(2) 12(2)(3) Requirement 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 timescales of 01/07/05 and 01/04/06 not met). Timescale for action 01/07/06 2. OP31 9(1)(2)(b) The registered person must ensure the home has a registered manager. 24(1)(a) (b)(2)(3) The registered person must ensure a quality assurance system is fully implemented. (Previous timescales of 01/07/05 & 01/04/06 not met). 01/08/06 3. OP33 01/08/06 4. OP37 17(1) The registered person must 26(1) 5(a) ensure compliance with Regulation 26 of the Care Homes Regulations 2001, visits by the registered provider. (Previous timescales of 01/07/05 & 01/04/06 not met). 01/06/06 Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 24 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 The carers would benefit from training in the completion of the care planning process. Bowlacre DS0000005562.V289946.R01.S.doc Version 5.1 Page 25 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. 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