Inspection on 21/04/05 for Bowlacre

This inspection was carried out on 21st April 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 19/10/05

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, SK14 4EZ Lead Inspector Janet Ranson Unannounced 21st April 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. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bowlacre Address Elson Drive, Stockport Road, Gee Cross Hyde, SK14 4EZ 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) 0161 368 2615 0161 368 6015 bowlacre@aol.com Bowlacre Housing Association Bowlacre, Elson Drive, Stockport Road, Gee Cross, Hyde, Tameside, Anne Irwin CRH Care Home 37 Category(ies) of DE(E) Dementia - over 65 (6) registration, with number OP Old age (37) of places PD(E) Physical disability - over 65 (4) Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service Users up to 37 OP, up to 6 DE (E) and 4 PD (E) 27 August 2002 Date of last inspection 30th November 2004 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 of which have en-suites. On the ground floor there are two sitting rooms, one dining room and a large conservatory. In place are aids and adaptations 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 F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 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. A manager registered by the Commission for Social Care Inspection is in day-to-day control and was present during the majority of the inspection, as was the chairman who is also a registered person and newly in post. He described his vision for the future of Bowlacre and has devised a five year plan to promote it. 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. The home is working towards the Investors In People award. This was an unannounced inspection, carried out over 11 hours. The case files and care plans examined as part of the inspection concerned a newly admitted person, a person whose needs had changed, a person with a diagnosis of dementia and a person who had lived at the home for a long time. Where possible, the same residents were also invited to talk with the inspector about their experiences of the service. A further resident and her visitor also assisted the inspector at this time. A total of five staff described their roles and responsibilities during the latter part of the inspection. Requirements made at previous inspections were also checked for compliance. What the service does well: Meals are individually served in the dining room or in the residents’ own rooms. There is a choice at each mealtime and the daily menu is displayed in the dining room. According to the residents, one of the best things at Bowlacre is the quality and variety of the food. The staff are enthusiastic and benefit from training provided by the organisation. The residents said they were made to feel safe and secure whilst living at Bowlacre. Visitors confirmed they were made to feel welcome at the home. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 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 F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4 & 5 Users of the service are not provided with sufficient information prior to admission to make an informed choice about the home. Failure to fully document the initial assessment could result in individual needs not being met. EVIDENCE: The statement of purpose, service user guide and the statement of terms and conditions were in draft forms. This situation remains unchanged, despite requirements made at previous inspections. Four residents’ files were examined; each one contained an assessment made by the home in the case of privately funded residents or an assessment carried out by a social worker. The home uses a commercially produced document to complete an assessment of needs; it is a good system, provided all the prompts are completed. This document had not been completed in its entirety and only one such assessment out of the four examined was signed by the resident. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 9 The carers are responsible for completing the assessment and at interview demonstrated their understanding of the process. It is important that the supervisor monitors the quality and content of the written details to ensure all needs are identified. This is required as the initial assessment forms the basis of the care plan. One resident understood that an assessment had been completed whilst she was in hospital, and a resident’s daughter confirmed she had been involved in her mother’s assessment of need. The residents confirmed they had visited the home before they were admitted. The carers said this was usually the case, although they did not always visit the prospective resident at their home or hospital. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 & 11 Shortfalls in the care planning processes have the potential to put the residents’ health and welfare at risk. The systems and administration of medications enabled the residents, where possible, to safely self-administer their own medication. The staff training and practice respected the residents’ privacy and dignity. EVIDENCE: Four care plans were examined. The individual care plan is based on information obtained and documented at the initial assessment of need. Where this is incomplete, the care plan will also be deficient and this was found to be the case. The written entries in one case were muddled with follow on information contained in the wrong area of the plan and a whole care plan was missing from the (same) resident’s case file. It was obvious from this that the care plans are not being reviewed or used on a daily basis by the carers. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 11 Despite 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. The risk assessments were also incomplete and not thoroughly reviewed. Treatment for one resident’s pressure sore had not been documented as a risk, and was unknown to the registered manager. Nutritional screening had been documented but warning triggers had not been followed up, thereby placing the resident at risk from malnutrition and pressure sores. The District Nursing service was in attendance on the first day of the inspection, they confirmed they were visiting five residents. A podiatrist was also visiting the home at the time of the inspection. Four medical administration records (MAR) were examined and were found to be maintained in a satisfactory manner. Recent problems with the administration of medications have been addressed by ensuring two senior staff are on duty and a change of pharmacist has been beneficial. At the time of the inspection, one resident continued to self-medicate and a risk assessment was in place. The controlled drugs register was examined. The retained medication agreed with the total in the register. During discussion with the carers, they confirmed they had received training in the correct medication administration. The pre-printed care planning documentation prompts the writer to obtain information concerning the resident’s last wishes. This important information had not always been completed, the lack of which could result in failure to carry out a resident’s specific arrangements. Three residents stated that the carers treat them with respect and their privacy is maintained at all times. The carers were able to demonstrate how they respected the residents’ privacy by knocking and waiting for a response before entering residents’ rooms. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 & 15 The social activities and trips out fulfilled the various needs of the residents. Meal times are flexible and relaxed. The menu provided choice and the content was nutritious and well balanced. EVIDENCE: All the residents who spoke to the inspector said that the food was one of the most enjoyable things about living at Bowlacre. They confirmed the choice at each mealtime met with their needs and, at times, exceeded their expectations. The daily menu was displayed in the dining room and each table was nicely laid for four residents. The chef remains highly motivated. He has attended several training courses concerning specialist dietary requirements. On the second day of the inspection, one resident was going shopping with an (off duty) carer, she said that she usually went on the arranged trips and was aware of a forthcoming trip on the canal. A further resident said that she did not always want to take part in activities and felt able to go to another part of the home at this time. The carers do not insist she takes part. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 13 A plan to employ a full-time activities organiser had not been forthcoming but it was felt that current staffing levels enabled carers to provide stimulation during the day. Visitors to the home were welcomed by the staff and invited to have light refreshments during their stay. One visitor stated this made her feel part of a larger family and was much appreciated. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 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 standard(s) 16 & 18 The residents were certain their complaints would be listen to and addressed. Practices in the home ensure the residents are protected from abuse. EVIDENCE: In discussion with three residents, they all stated that if they had a complaint they would speak to the manager or a member of their family. They all felt that their complaint would be handled in confidence. This confidence was not based on experience and none of those spoken with had seen a copy of the written procedure. The carers who spoke with the inspector were aware of the complaints procedure and confirmed they would try to solve a complaint at source but would also report back to the senior person in charge at the time. All the care staff have received specialist training in the prevention of abuse and clearly demonstrated their understanding and actions to be taken in response to an allegation. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 15 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) 19 & 26 Bowlacre is a well maintained home with good standards of hygiene and cleanliness. EVIDENCE: Since the last inspection Bowlacre has redecorated the main entrance, hallway and staircase. Carpeting to this area has also been carried out to good effect. Personnel employed by Bowlacre carry out internal and external maintenance to the building and grounds. There is a planned maintenance and improvement programme built into the home’s budget. The chairman of the organisation provided evidence of the forthcoming improvements to the property and grounds in the form of a business plan. The residents stated they were satisfied with the standard of their accommodation and facilities. They stated the home was always clean and, above all, they felt safe, a response which contrasted with their experiences whilst living in the community. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 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 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, 29 & 30 Recruitment processes provide safeguards to the residents of Bowlacre. There is a good mix of age and experience in the staff group who benefit from training in both specialist areas and mandatory requirements. EVIDENCE: The turnover of staff has improved and the home no longer relies on agency staffing, which was not the case at the previous inspection. There is a good mix of age and experience within the staff group. During discussion with four carers the inspector was impressed with their enthusiasm and willingness to undertake training. One carer said it was the best home she had ever worked in. All four of the carers confirmed they had gone through a period of problems with staffing. The residents spoken with stated the carers were very kind and caring, “even though they are very young.” Response time when the call system was used (during the night) was satisfactory and the residents also stated that they could have a hot drink and a snack during the night if they wished. Matters concerning recruitment practices identified at the previous inspection had been addressed. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 17 All the staff stated they had good training opportunities. They had received induction and mandatory training to ensure the safety of the residents and visitors. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 18 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) 31, 33, 34, 35, 36, 37 & 38 The home continues to be run in a disorganised and muddled manner due to the lack of overall leadership from the manager. The home’s policies and procedures protect the safety and welfare of residents. Staff benefit from a programme of structured supervision. EVIDENCE: The registered manager is yet to complete the National Vocational Qualification level 4 (registered manager’s award) as required from the last inspection. A number of areas of the home’s operation that are directly the responsibility of the manager to address had not improved since the last inspection. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 19 The quality and maintenance of the recording systems in the home remain a cause for concern. Time and effort was spent by senior staff during the inspection looking for information that should be readily to hand. The manager appeared disorganised, which affected an otherwise satisfactory inspection and gives an unprofessional impression. A quality assurance package has been purchased, along with the associated training provided by the company. The registered manager and other senior staff have attended the training. There was no evidence of the quality assurance package having been implemented but it is understood that the home is working towards the Investors in People award. The residents who spoke with the inspector did not want to be involved in the running of the home but did show interest in making suggestions about the menus or trips out. They confirmed there was no means of making such suggestions. The newly published newsletter provides the residents, their families and visitors with interesting details, forthcoming events and local news. A five year business plan was examined by the inspector. It was reported that three residents manage their own finances; the majority have either family involvement or solicitors. One resident confirmed she managed her own affairs and one other said that her relative had enduring power of attorney, an arrangement made before she moved into the home. A programme of formal supervision is newly in place. The team leaders have received training and impressed the inspector with their understanding and application. Carers in receipt of supervision expressed their initial anxiety but are now aware of the benefits both for themselves and the residents. Staff have attended health and safety training, thereby ensuring, as far as possible, the safety of residents, their visitors and the staff. Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 20 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 1 1 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 2 3 3 3 1 3 Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 21 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 1 Regulation 4(1)(a)(b) (c) 5(1)(a)(b) (c)(d)(e) (f)(2) Schedule 1 5(1)(b) Requirement Timescale for action 01/07/05 2. 2 3. 3/4 14(1)(a) (b)(c)(d) (2) 4. 7 15(1)(2) (a)(c)(d) The registered person must ensure that the statement of purpose and service users guide meets with the requirements and is made available to the service users. (Previous timescale of 01/03/05 not met). The registered person must 01/07/05 ensure that all service users have a statement of terms and conditions (or contract if the service user is self funding) at the point of moving into the home. (Previous timescale of 01/03/05 not met). The registered person must 01/07/05 ensure that initial assessments contain sufficient details to enable the carers to meet the residents needs. The assessment must be kept under review and revised as required. (Previous timescale of 01/03/05 not met). The registered person must 01/07/05 ensure that care plans are completed in sufficient detail to provide clear instructions to the carers on the action to be taken to fully meets the needs of the residents. Such care plans must Version 1.30 Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Page 22 5. 8 6. 7. 11 31 8. 9. 33 37 be kept under review. (Previous timescale 01/03/05 not met). 12(1) The registered person must 13(1) ensure the risk from pressure 17(1)(a) sores is assessed, documented schedule and reviewed. All treatment 3 must be recorded in the individual care plan. 12(2)(3) The registered person must ensure the residents final wishes are documented and carried out. 9(1)(2)(b) The registered manager must ensure achievement of National Vocational Qualification level 4 (registered managers award). 24(1)(a) The registered person must (b)(2)(3) ensure the quality assurance system is implemented. 17(1)(a) The registered person must (b) 26 ensure all records required by legislation are kept in good order (1)(2)(a) (b)(c)(3) well maintained and presented. (4)(a)(b) The registered person must also (c) ensure compliance with 5(a)(b)(c) Regulation 26 of the Care Homes Regulations 2001, visits by the registered provider. (Previous timescale of 02/01/05 not met). 01/07/05 01/03/05 30/04/05 01/07/05 01/07/05 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 Good Practice Recommendations Bowlacre F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor Heritage Wharf Portland Place Ashton under Lyne, 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 F54 F04 s5562 bowlacre U v222161 210405 stage 4.doc Version 1.30 Page 24 - 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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