Inspection on 25/06/07 for Bowlacre

This inspection was carried out on 25th June 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bowlacre 02/05/06

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 5EZ Lead Inspector Janet Ranson Unannounced Inspection 25th June 2007 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.V339202.R01.S.doc Version 5.2 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.V339202.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bowlacre Address Elson Drive, Stockport Road Gee Cross Hyde Tameside SK14 5EZ 0161 368 2615 0161 368 6015 bowlacre@yahoo.co.uk 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 Janette Frances Wilson 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.V339202.R01.S.doc Version 5.2 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 2nd May 2006 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. Fees for accommodation and care at the home range from £331.75 to £376.25. Additional charges are also made for hairdressing and chiropody services, newspapers and some personal toiletries. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the key inspection, which included an unannounced site visit. The site visit took place on 25th June 2007 and covered a period of eight hours from 09:30 until 17:30. The service had previously completed an annual quality assurance assessment (AQAA) and a data set that gave the inspector certain information about the provision. From these details a selection of service users and their relatives were invited to complete a small survey setting out their comments on identified care issues. A total of four residents’ identified needs were closely looked at by the inspector. Individual details of their experiences and care were examined from when they first came into the home to their current care needs. The inspector also talked to four residents about their quality of life, 2 relatives and 2 carers also assisted the inspector with their comments on the service. The inspector looked around the building and checked a selection of staff and residents’ records. In addition to a team of carers the service employs catering, domestic staff, a maintenance person and contract gardeners. A visit to the service was also carried out on the 25th October 2006. This visit was as a result of 2 complaints made directly to the Commission for Social Care Inspection and an anonymous email signed from “a concerned member of staff.” Details of the visit are contained within this report. What the service does well: The home provides the resident’s with well-maintained accommodation. The standards of cleanliness and hygiene are very high. Visitors to the home say they are made to feel welcome. The residents and a visitor were positive about the standard of care offered, and in particular about the friendly and helpful attitude of the staff team. The quality of the meals provided continues to be of a high standard. The residents confirmed they had a good range of options to the main meal. The visitors are encouraged to have meals with their relatives. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 6 The carers said they enjoyed working at Bowlacre and felt supported in their role. The home continues to be committed to National Vocational Qualification (NVQ) at levels 2 and 3. All carers have either achieved level two (or above) or are enrolled on the course. 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. The summary of this inspection report can be made available in other formats on request. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 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.V339202.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 Intermediate care is not provided at Bowlacre.) Quality in this outcome area is good. The home’s system of assessment reflected individual preferences and social requirements. This meant that the home could be certain they could meet the prospective resident’s diverse needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual care needs assessments were contained within the four care files examined as part of the inspection. The home also has a process of assessing potential residents’ needs carried out by a senior member of staff. Where ever possible the service invites the prospective resident and their relatives to visit the home so that they can meet other people and see the Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 9 accommodation for themselves. By completing such an assessment the home can be sure that individual needs can be met. A resident said she had sampled a meal before she decided to live at Bowlacre, and a visitor confirmed they had looked around the home on their relatives’ behalf. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. The care planning process identifies the residents’ individual health and social requirements. They provide the carers with action to be taken to provide appropriate care on a day-to-day basis enabling the residents to benefit from the individual care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were examined as part of the inspection process. They set out the residents’ individual personal care needs. The care plans document the action to be taken by the carers to ensure all aspects of health, personal and social care are met and reviewed. Risk assessments were in place including those people identified as being at risk from falling. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 11 Where identified, the resident’s health is monitored and addressed by the appropriate health care professionals. The district nurses are involved on a regular basis as are the chiropodist, audiologist, dietician and speech therapist. There has been a history of poor recording practices at this home. It was apparent that the carers had worked hard to improve this situation in order that the residents are cared for in the most appropriate manner. The manager must continue to supervise this process particularly where people have been admitted in an unplanned manner. Those residents who spoke with the inspector were unfamiliar with their written care plan but said they were happy with the care they received. A visitor said they were involved in the planning process both at the home and with the social worker. The senior staff are responsible for the administration of medication. There was evidence to show they had received training to correctly administer medications. Records are retained to show changes to medications and medical interventions. There is a policy and procedure in place to ensure all medications are administered in the correct manner. The medication storage was satisfactory. The home operates a “care pathway” system for those residents who have been assessed by a doctor as being in their final stages of life. This involves other healthcare professionals in addition to the homes care staff enabling the resident to remain in their own room whilst receiving specialist care. The manager confirmed they had been involved recently with the care of a person who was dying. She felt that working closely together with the other healthcare workers provided the resident and their relatives with a good service, which also allowed the person to remain in familiar surroundings. Based on observation, it was apparent that the staff respected the residents’ privacy by knocking and waiting before entering rooms. The carers responded to the residents in a respectful manner. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. The choices offered to the residents meet with their requirements and recognises their religious and cultural diversity. This enables them to exercise elements of control over their lives in addition to providing social stimulation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection the residents were recovering from the previous day when there had been a garden party at the home. The party is an annual event that enables families to get together in an informal manner. The chairman of the committee said that seven families of residents who no longer lived at Bowlacre also came to the party. It was apparent from speaking to the carers that the resident’s relatives were well known and welcome to the home. From observation the visitors were at ease with the staff and the other residents. A visitor to Bowlacre leads a small group of people in an art activity. The pictures are displayed in the dining room. During the inspection some Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 13 residents could be seen in the dining room, drawing a vase of flowers. Jigsaws were available along with daily newspapers. Gentle exercises to music are carried out at regular intervals and there are entertainers brought into the home. A resident and her visitor were enjoying Wimbledon on the television in the lounge to the rear of the building. The church visitors also use this lounge where there is an electric organ. This area has been redesignated as the activities lounge so that the residents who choose not to participate can remain in the communal area. The home has a system of outlining the resident’s previous life history. The completed document details religious, cultural and recreational interests and is retained in the individual care file. Where ever possible the residents and their families are involved in this process. This helps the carers to better understand the residents needs and is considered to be very good practice. The daily menu was displayed on a wipe clean board in the dining room. The main meal of the day is served at lunchtime. The inspector looked at the weekly menu, the content of which was balanced with options to the main meal documented. Medical diets are well catered for; this was confirmed by a resident who required a special diet. She said she always had meals that were tasty and appropriate for her needs. The dining tables were arranged for groups of four people and the meals were observed to be pleasantly served and well presented. This was obviously a social event helped by quiet music playing throughout the meal. After the meal the residents voiced their satisfaction to the inspector and generally commented on the excellent quality of the meals. One resident said she particularly enjoyed the sausages, as they were “nice and spicy.” The kitchen assistant said they had been especially bought for a resident who had said she liked the Lincoln type of sausage. The alternative to sausage was a pork casserole, fresh cauliflower and broccoli and creamed potatoes. The sweet was strawberries and ice cream. Two visitors said they thought the quality of the meals was high. They also knew they could have meals (for a small charge) with their relatives if they wished. Arrangements are in place to meet the new none smoking legislation that comes into force on the 1st July 2007. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system with evidence that residents feel that their views are listened to and acted upon. Staff knowledge and understanding of adult protection issues provides a safe environment to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A random visit was carried out in Oct 2006 as a result of two complaints from relatives of people who lived at Bowlacre. An email signed “a good carer” setting out certain concerns had also been received by the Commission for Social Care Inspection. It was accepted at this time that the complaints the home had received had been thoroughly investigated within the timescales and by the correct personnel. One complainant remained dissatisfied with the outcome and had been invited to further discuss the issues with the chairman. The details outlined in the fax were discussed with the chairman and the manager. Some issues had already been discussed during a recent staff meeting. Due to the anonymity it was not possible to respond further to this complaint. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 15 Requirements concerning the environment and health and safety issues were made as a result of the random inspection. During this visit the inspector asked certain residents what they would do if they were not satisfied with the help they receive. Two people said they would tell their relative and expect that there would be an improvement. Two visitors said they were aware there was a complaints process “in the documentation they had received”, but would chose to speak directly to either the manager or the chairman. They went on to say they had faith their concerns would be addressed and that the manager and the chairman were regularly available. In discussion with the carers they clearly knew that any complaints had to be brought to the managers attention. With regard to the protection of vulnerable adults (POVA), two carers said they had touched on this as part of their NVQ course. They clearly demonstrated to the inspector their understanding of the term “abuse” and of their responsibilities concerning safeguarding the residents from harm. Since the last inspection there has been no safeguarding issues or formal complaints made to the Commission for Social Care Inspection. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. The residents and their visitors are provided with a safe, warm and welcoming environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A random inspection was carried out in October 2006 after a complaint from a relative and an anonymous member of staff. Part of the complaint alleged that the home was not hygienic, the conservatory was leaking and the electricity in this area not working. During this visit it was found that the home was clean and free from offensive odours. The inspector was advised that conservatory did indeed leak. The Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 17 failure of electricity in this area concerned supplementary heating. Requirements were made at this time concerning these issues and it was agreed that in the event of inclement weather the residents would be invited to use other areas of the home. The requirements concerning the conservatory have been addressed and the inspector is satisfied that this (very popular area) is now weatherproof and the supplementary heating is fully functional. The housekeepers continue to keep the home in a clean and hygienic state. The visitors confirmed this to be the usual state of the home. A resident said her room is “spotless” and her bed “always very clean.” The gardens surrounding the home are a particular feature and are well maintained. A resident said she always tried to sit outside in the better weather. The garden to the rear is fully accessible from the home. There are plans to improve the paths to make them easier for those people in wheelchairs or using Zimmer frames. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. The residents receive care from an enthusiastic, well-trained staff that responds to the residents and visitors in a respectful manner. The home’s recruitment policy and procedure provides protection to the residents from potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observation during the inspection the numbers of staff on duty met with the residents’ assessed needs. A rota was available for inspection but not examined at this time. Each resident has a carer allocated to them. This person is known as a key worker. The carers told the inspector that they had a special relationship with “their” residents and families. This is a good model of care, which not only provides care for the individual but also support for their family and friends. The carers told the inspector they enjoyed working at Bowlacre. They felt supported by the management who were very “approachable”. They also said the lines of communication were good with regular staff meetings and formal Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 19 supervision. The staff felt the home had a good reputation for looking after the residents. Bowlacre. They felt supported by the management who were very “approachable”. The staff felt the home had a good reputation for looking after the residents. A small number of staff files were examined. They contained the required documentation and there was evidence of references including satisfactory checks with the Criminal Record Bureau. The files were organised and well maintained. The home is committed to the National Vocational Qualification system. It was reported that all the carers had either achieved level 2 (or above) or were enrolled on the training. The mandatory training in health and safety issues is provided for all the staff. Additional training is also available through the local consortium. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. The manager of the home has the skills, experience and qualifications to run the home in the resident’s best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has the appropriate skills and experience to manage Bowlacre, where she has worked for the past four years. Since the last inspection the manager has been registered (as required) with the Commission for Social Care Inspection. This means she is considered to be a fit person to be responsible for the management of the home. She is studying towards her National Vocational Qualification at level four and the required Registered Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 21 Managers Award. It is anticipated this will be achieved by the end of the week. There was further evidence to show that she continues to update her knowledge and skills by attending various courses. The home has a system to protect financial interests for those residents who are no longer able to deal with their money. An administrator maintains satisfactory records of expenditure. The care plans and risk assessments were found in the main to be up to date and regularly reviewed as are the homes policies and procedures. The home uses part of a quality assurance system that is specifically designed for care homes purposes. Quality satisfaction surveys are sent out at regular intervals. The residents also have meetings where they are encouraged to contribute their thoughts about various issues. A newsletter is devised for the purpose of keeping the residents and their visitors up to date with the various comings and goings, birthdays and future events. A tripping hazard was noted in the carpet on the first floor landing. This was brought to the attention of the manager and chairman at the time. No other hazards to health were noted during the inspection. The health, safety and welfare are further ensured by the systems in place to report any accidents and incidents. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 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 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 13 14 15 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 3 3 3 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 X X 3 Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP28 Good Practice Recommendations In order to prevent the risks from cross infection the staff should be reminded to wear protective clothing whilst supporting the residents with their meals. Bowlacre DS0000005562.V339202.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V339202.R01.S.doc Version 5.2 Page 25 - 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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