Inspection on 27/09/05 for Bowland Lodge

This inspection was carried out on 27th September 2005.

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 26/01/06

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 1:30 27 and 28 September 2005 th th 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.V255584.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.V255584.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.V255584.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2004 Brief Description of the Service: Bowland Lodge is a care home that provides personal care to 36 older people and older people with dementia. The home is located within a residential area of the west end of Newcastle upon Tyne. The property is a large converted Victorian house, over three floors. A new passenger lift has recently been installed. There is easy access by public transport and to local amenities and shops. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days in September. It took five and a half hours in total. The registered manager was present throughout the inspection. Discussions took place with residents, relatives and staff. Time was spent studying care records and a range of other records. The building was toured. What the service does well: The home always makes sure that it can fully meet all the needs of new residents before they come into the home. The home draws up very detailed care plans to meet those needs. The home looks after the health of its residents very well. There is a good range of social activities for residents to enjoy. Relatives are made welcome in the home at all times. Relatives speak highly of the manager and her staff, and of the care being given. There is a good, varied menu, with lots of flexibility and resident choice. Residents say they enjoy the food. Any complaints are taken very seriously and properly sorted out. Residents feel that the staff listen to them. All staff have had training in how to keep residents safe from harm and abuse. The home is clean, pleasant and hygienic. The home is well managed, and is run in the best interests of the residents. The health and safety of staff and residents is protected. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bowland Lodge DS0000000434.V255584.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.V255584.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): 3,4. New residents have a full assessment of their needs before they are admitted to the home. The home demonstrated that it is meeting the assessed needs of the residents. EVIDENCE: Study of a sample of residents’ care records showed that a full Community Care Assessment is always received from a person’s social worker or care manager before they are accepted into the home. There is also a very full range of assessments carried out by the home. These include pre-admission, social, spiritual, manual handling, C.A.P.E. and Activities of Daily Living assessments. There is evidence in the minutes taken of the initial reviews (usually four weeks after admission, then every six months) that the home is constantly checking that it can meet residents’ needs. Bowland Lodge DS0000000434.V255584.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): 7,8. Residents’ health, social and personal care needs are fully addressed in their individual care plans, which are very detailed. The health care needs of residents are being fully met. EVIDENCE: A study of a random sample of residents’ care records showed that care plans are in place for virtually all assessed needs. Care plans are holistic, detailed and sensitive. They include a clear statement of the resident’s needs, have achievable goals, and detailed staff interventions. Care plans are evaluated every month. The manager is planning to make social care plans more individual to each resident, to fully reflect their known hobbies, interests and preferred lifestyles. It was a recommendation of the last inspection report that physical care charts should be kept up to date. This has been put into practice. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 10 Residents’ health care needs are regularly assessed. There are clear records kept of all visits to or by health professionals, including opticians, doctors, chiropodists, dentists and nurses. Any changes in a resident’s health are recorded in their care records, and there are detailed handovers between shifts, including night staff, who carry out hourly checks of residents throughout the night. Any health problems noted are properly responded to. Relatives confirmed that health needs are met. Care records and anecdotal evidence showed that many residents have improved in areas such as weight, diet, mobility, memory, continence, communication and general wellbeing since coming to the home. Bowland Lodge DS0000000434.V255584.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): 12,13,15. The home works hard to identify residents’ social, religious, cultural and recreational needs, and makes every effort to meet those needs in positive ways. There is good social stimulation. Relatives are made welcome in the home at all times. Residents have a good, balanced and varied diet, and there is always a lot of choice. EVIDENCE: Every resident has a social assessment carried out (unless they specifically refuse this) and some very good examples were seen, giving a life history, family and social contacts, likes, dislikes, hobbies and interests. The manager is currently working on making sure that every resident has a social care plan that properly reflects this very individual approach. There are activities in the home every day, and these are recorded in a diary. Some examples of the activities offered are arts and crafts, bingo, quizzes, church services (weekly), trips out, visits to pubs, cards and dominos. The staff are flexible to residents’ wishes, and often activities are spontaneous. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 12 There are occasional visiting entertainers, a recent highlight being the visit of the local Salvation Army band. The home celebrates all key events, such as Easter, Halloween, Valentine’s Day, Remembrance Day, and all residents’ birthdays. Visiting relatives spoke highly of the activities in the home, and of how they always included in activities and events. There is a four-week menu. There is a good degree of choice within the menu and the cook is very flexible. A cooked breakfast is available every morning. There is a choice of two main courses for lunch, with salads and any other alternative a resident may request. This is good practice. There is a hot meal, plus dessert for tea, and sandwiches, cake etc. for supper. Each person’s menu choice is recorded daily. The home caters successfully for one resident from an ethnic minority. Residents and visiting relatives confirmed their satisfaction with the food. The manager is planning nutritional training for staff. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Residents feel that they are listened to by staff and are confident that any worries that they may have would be quickly sorted out. Staff have been trained to recognise all aspects of abuse and to protect residents from abuse. EVIDENCE: The home’s complaints book was examined. Two complaints have been recorded in the past year, both about the appearance of residents. Both were properly investigated by the manager within 48 hours, and responded to in writing. She accepted that both were substantiated. It was apparent throughout the inspection that the manager has a very open and honest approach to the inspection process, and to the work in general. She accepts that the service is not always perfect, and responds positively to complaints and all other feedback, using it as evidence to improve the service. It was advised that the complaints book is re-titled the ‘Comments, compliments and complaints’ book, to encourage feedback, both positive and negative. Staff are currently being given training in the Protection of Vulnerable Adults (POVA). This is in the form of a weekly session for twelve weeks. This is good practice. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 14 The home’s POVA policy and procedure has recently been updated to reflect current best practice in this important area. No protection issues have arisen in the past year. Residents confirmed that they feel safe in the home, that they are listened to by staff, and that they would feel confident in raising any concerns or complaints they may have with the staff. Visiting relatives also said they feel valued and that the manager and staff take their opinions seriously. They confirmed that the manager’s door is always open to them. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 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 the following standard(s): 19,21,24,26. Residents live in a safe and generally well-maintained home, but some further work is still required. There are enough toilets and washing facilities, other than in one bedroom, which does not have a wash hand basin. Bedrooms are safe and comfortable, and residents may bring their own possessions to the home, including furniture. The home is clean, pleasant and hygienic. EVIDENCE: The building was toured. It has had significant redecoration since the last inspection. Five bedrooms, all the lounges, the dining room, the ground floor corridor, toilet and bathroom have all been redecorated. There has also been some furniture replaced. A bathroom is being converted into a shower room. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 16 The part of the dining room carpet that is nearest to the kitchen is very heavily soiled and must be replaced with washable floor tiles. The door into the kitchen was wedged open, to allow staff to move food trolleys through from the dining room. This is an unacceptable fire risk, and an alternative method of safely holding open the door must be found (details of approved devices are available from the CSCI and the Tyne & Wear Fire Service). Service records were examined. They were up to date. Risk assessments have been carried out recently on the building. The accident book was examined. The manager follows up each entry and also analyses data on accidents in the home. It was found that there have been fewer accidents in the past twelve months, compared with previous years. A requirement has been made in the last two 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. It was a further requirement of the last inspection report that all bedrooms must be provided with lockable door and lockable storage space (unless the reason for not doing so is risk assessed and recorded). This has been implemented, and suitable risk assessments were seen, where required. The home was found to be clean, pleasant and hygienic. There were no offensive odours. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 17 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): 27,29,30. There is a sufficient number of skilled staff to meet the needs of the current number and dependency levels of residents. The home’s recruitment policy and practices give protection to the residents. 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: The home’s staff rotas were inspected. The home had fewer residents (22) than at previous inspections, and a temporary reduction from four to three carers between the hours of 8am and 8pm was agreed. The home must revert to having four carers between these hours when occupancy increases to 24 residents. There is always two night staff on duty. There are 61 catering hours, and 56 domestic/laundry hours. These are acceptable levels. The manager is mainly supernumerary to the rota. Visiting relatives confirmed the manager’s opinion that she has a stable, experienced and mature staff group, who are very flexible, very caring, and Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 18 who have achieved some very good results in the personal development of residents. A sample of staff personnel records was examined. All had the necessary written references, police checks, proof of identity, and fully completed application forms. Any gaps in employment are checked in interview, and a job interview assessment form is completed. New staff contracts are being developed. Clear records are kept of staff training. Staff receive induction training and the required statutory training. There is a training and development plan, and a good level of future training is planned. The home has exceeded the target for having at least 50 of care staff qualified to National Vocational Qualification (NVQ) level two, having 63 now qualified, and another two about to start this course. In addition, four care staff have gone on to achieve NVQ level three. This is commendable. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 19 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): The home is well managed. The home is run in the best interests of the residents. Staff are supervised, but not as regularly as is required. The home meets its obligations for looking after the health, safety and welfare of its residents. EVIDENCE: The manager demonstrated, throughout the inspection, that she is residentcentred in her approach to the running of the home. Mrs Parkin is experienced and well organised, knowledgeable, and is pursuing further qualification (NVQ level four). Feedback from visiting relatives, discussions with the manager and staff members, and study of the care records all confirmed that the home is run in the best interests of the residents. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 20 Staff supervision takes place and is recorded. However, it is not given as frequently as is required. In discussion with Mrs Parkin, it was agreed that there is a need for her to delegate some supervisory duties to her deputy. The accident book is kept up to date. The manager reads and countersigns all entries. The fire logbook showed that fire equipment and fire systems are regularly checked and serviced. Staff had fire training in August this year. Fire risk assessment has recently been completed, and risk assessments regarding the building, harmful substances and individual residents are all in place. Equipment is regularly serviced, to make sure it is safe. Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 21 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 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 22 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 OP19 Regulation 23(2) Requirement The heavily soiled area of the dining room carpet, next to the kitchen, must be replaced with washable floor tiles. A wash hand basin must be provided in the toilet opposite room 29. (This requirement is outstanding from 22 May 2004.) Care staff must receive formal supervision at least six times each year. Timescale for action 30/11/05 2 OP21 23(2) 30/11/05 3 OP36 18(2) 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bowland Lodge DS0000000434.V255584.R01.S.doc Version 5.0 Page 23 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.V255584.R01.S.doc Version 5.0 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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