Inspection on 26/01/06 for Bowland Lodge

This inspection was carried out on 26th January 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 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

Bowland Lodge 17/09/09

Bowland Lodge 20/08/09

Bowland Lodge 20/09/07

Bowland Lodge 25/07/06

Bowland Lodge 27/09/05

Bowland Lodge 05/10/04

Bowland Lodge 22/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Bowland Lodge Western Avenue Newcastle Upon Tyne Tyne & Wear NE4 8SP Lead Inspector Alan Baxter Unannounced Inspection 13:00 26th January and 2 February 2006 nd 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 Bowland Lodge DS0000000434.V257690.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. Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bowland Lodge Address Western Avenue Newcastle Upon Tyne Tyne & Wear NE4 8SP 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) 0191 273 4187 0191 2323239 Mr Ram Perkesh Malhotra Mr Darshen Kumar Malhotra Mrs Linda Parkin Care Home 36 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (12), Old age, not falling within any other of places category (22) Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005. Brief Description of the Service: Bowland Lodge is a care home that provides personal care to 36 older people and people with dementia. The home is located within a residential area of the west end of Newcastle upon Tyne. The three storey property is converted from two adjacent Victorian houses. A new passenger lift has recently been installed. There is easy access by public transport and to local amenities and shops. Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two days in January and February 2006. The main focus of this inspection was to check whether or not the home had implemented the requirements and recommendations of the last inspection report, so not all the standards were assessed on this visit. Care records and other relevant documentation were studied. Parts of the building were toured. Residents, staff and a visiting social worker were spoken with. The inspection took approximately five hours in total. What the service does well: What has improved since the last inspection? Staffing levels have been increased, in line with increased resident occupancy. Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 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. Bowland Lodge DS0000000434.V257690.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 Bowland Lodge DS0000000434.V257690.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): These standards were not assessed on this inspection. EVIDENCE: Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 9 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): 9,10. 9) Residents are not fully protected by the home’s current practices regarding medicines. 10) Residents feel that they are treated with respect by staff at all times. EVIDENCE: 9) The home has appropriate policies and procedures for dealing with medicines. These allow for residents to self-administer their medicines (although no current residents are able to do this). Only trained, designated staff give out medicines. Three staff have recently passed a ‘Medication Awareness’ exam via Gateshead College, and three others are retaking this exam. The home uses the ‘blister pack’ system, supplied by a local Pharmacist. The Medicine Administration Record (MAR) appeared to be fully completed, but an audit of one resident’s medicines showed that no resident’s medicines had been signed as having been given that day. The manager stated that these Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 10 medicines had been administered, but could not explain why the MAR had not been completed for that day (previous days had been fully recorded). It is a requirement that all medicines are recorded immediately that they are administered. It is a further requirement that all handwritten entries in the MAR are signed and dated. 10) Those residents spoken with in the course of this inspection confirmed that they are always treated with respect by the staff. Care records also confirmed that residents’ rights, dignity and privacy are an important part of the home’s care. Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 11 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. 14) Residents are encouraged to have as much control over their lives as possible. EVIDENCE: 14) There was ample anecdotal, documentary and observed evidence that residents are encouraged and supported to be as independent as possible, and to take as much control of their own lives as possible. Examples given included choice of times of rising and retiring (indeed, whether to go to bed at all); what to eat, and when; going out independently (subject to risk assessment) and using local leisure facilities and shops; and choosing which visitors they wish to see, and where they wish to entertain them. A number of residents handle their own financial affairs, including collecting their own pensions, paying their own fees and keeping their own pocket money. Residents receive their post unopened. Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 12 The option of leaving the home to live independently again is always considered to be a possibility, wherever a resident seems to have the potential for this. Advocacy is advertised in the home. Residents may bring items of furniture and other personal possessions with them when they come to the home. Residents may access their own care records, should they choose to do so. Bowland Lodge DS0000000434.V257690.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): These standards were not assessed on this inspection; however, standards 16 and 18 were assessed and met on the last inspection. EVIDENCE: Bowland Lodge DS0000000434.V257690.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): 19,21,26. 19) The home is in the process of carrying out a maintenance plan to bring the environment up to standard. 21) There are enough toilets and washing facilities, other than in one bedroom, which does not have a wash hand basin. 26) The home has recently employed a kitchen assistant to improve cleaning issues in the kitchen. EVIDENCE: 19) It was a requirement of the last inspection report that the heavily soiled area of the dining room carpet, next to the kitchen, must be replaced with washable floor tiles. This has not been implemented (although it was noted that this area of carpet had since been cleaned). Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 15 The requirements of the most recent inspection by an Environmental Health Officer were followed up in this inspection. These covered areas of kitchen cleanliness and repair. Certain items have not yet been addressed. The manager is sending a maintenance plan (received on 6th February) to demonstrate how the outstanding items are to be met. A kitchen assistant has now been employed, to concentrate on kitchen cleaning. 21) A requirement has been made in the last three inspection reports that a wash hand basin must be provided in the toilet opposite room 29. This work has still not been done, and must now be done as a priority. 26) Parts of the home were toured. Issues of cleanliness and repair were found in the kitchen area. The manager has since submitted a maintenance plan, drawn up a cleaning schedule, and employed a part time kitchen assistant. Bowland Lodge DS0000000434.V257690.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): 27,28. 27) Staffing levels are being brought up to the agreed minimum levels. 28) There is a good level of training made available to staff, and the number of staff who hold National Vocational Qualifications (NVQ) exceeds the 50 required. EVIDENCE: 27) Staff rotas were seen. At the time of the last inspection, the home had fewer residents than previously, and it was agreed that staffing levels could be slightly reduced at that time. Occupancy levels at this inspection had increased to 26 residents, and staffing had been increased to four between 8am and 2pm. The manager was reminded of the agreement at the last inspection to increase staff levels between 8am to 8pm, and she agreed to raise staff numbers from the following Monday. As noted in standard 19, above, a new post of kitchen assistant has recently been filled. 28) Study of staff training records showed that the home now has more than 50 of care staff qualified to at least NVQ level two. Bowland Lodge DS0000000434.V257690.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): 35,36. 35) Cash held on behalf of residents was not able to be inspected on this inspection. 36) Staff supervision is being given at the required regularity. EVIDENCE: 35) It was not possible to inspect cash held on behalf of residents because the only key to the safe where such cash is stored was in the possession of the home’s proprietor, who was not in the building at the time of the inspection. It is a requirement that the person in charge of the home must be able to access residents’ money for them on request, and therefore must carry a safe key. Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 18 36) Staff supervision minutes were inspected. Supervision is taking place at the required two monthly pattern. Minutes of supervision are detailed and informative. Staff appraisals are due. The manager currently does all staff supervision. It is recommended that other senior staff are trained to be able to assist in giving supervision. Bowland Lodge DS0000000434.V257690.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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 3 X X Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 20 YES. Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13(2) Requirement All medicines administered to residents must be immediately recorded in the Medicine Administration Record (MAR). All handwritten entries in the MAR must be signed and dated. A list of staff names, along with the initials used by them in the MAR, must be held at the front of the MAR to allow for proper audit. A photograph of each resident must be attached to his or her page in the MAR, as a means of correct identification. The home must fully implement the maintenance plan submitted. A wash hand basin must be provided in the toilet opposite room 29. (This requirement is outstanding from 22 May 2004.) The contraventions noted in the Environmental Health inspection of 13/10/05 must be addressed. The person in charge of the home must be able to access DS0000000434.V257690.R01.S.doc Timescale for action 27/01/06 2 3 OP19 OP21 23(2) 23(2) 31/03/06 31/03/06 4 5 OP26 OP35 23(2) 17(2) 31/03/06 28/02/06 Bowland Lodge Version 5.0 Page 21 money held on behalf of residents at their request or as part of an authorised inspection of the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bowland Lodge DS0000000434.V257690.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Bowland Lodge DS0000000434.V257690.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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