Inspection on 21/02/06 for Bowood Court Nursing & Residential Home

This inspection was carried out on 21st February 2006.

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

Bowood Court Nursing &... 04/11/08

Bowood Court Nursing &... 27/11/07

Bowood Court Nursing &... 05/09/06

Bowood Court Nursing &... 07/08/05

Bowood Court Nursing &... 16/12/04

Bowood Court Nursing &... 27/07/04

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

CARE HOMES FOR OLDER PEOPLE Bowood Court Nursing & Residential Home Hewell Road Enfield Redditch Worcestershire B97 6AT Lead Inspector Mrs Yvonne South Unannounced Inspection 21st February 2006 12:30p 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 Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bowood Court Nursing & Residential Home Address Hewell Road Enfield Redditch Worcestershire B97 6AT 01527 65115 01527 66645 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) Southern Cross Healthcare Services Limited Emma Louise Miles Care Home 59 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (59), of places Physical disability over 65 years of age (59) Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate no more than 27 people who require nursing care. 7th August 2005 Date of last inspection Brief Description of the Service: Bowood Court offers both personal and nursing care for up to a maximum of 59 older people who may have physical disabilities and/or needs associated with old age. Nursing care for 27 residents is provided on the ground floor and personal care for 32 residents on the first floor. A maximum of six residents may have dementia illnesses. The home is located close to Redditch town centre, which has good amenities. Bowood Court was first registered in 1998 and is purpose built. It offers single, en-suite accommodation for all service users on both floors and has a passenger lift. Communal lounges, dining rooms, toilets and bathroom facilities are available on both floors. There are gardens which are accessible to service users. Southern Cross Health Care Ltd owns the home and the registered manager is Ms Emma Louise Miles. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over two and a half hours from 12.30pm until 3pm. The focus was on the requirements and recommendations that had arisen out of the previous inspection and key standards that had not previously been assessed this year. The inspector was assisted by the registered manager Mrs Miles and spoke to residents and staff. A range of records was assessed and a tour of the home was conducted. What the service does well: What has improved since the last inspection? Since the last inspection several areas had been re-carpeted and the dining room floors had been replaced. The information in care records was more detailed in some areas. The management team was stable and staff were receiving regular supervision and support. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed during this inspection. However compliance with the requirements set in the previous report was checked. Requirements were made that all residents being admitted to the home should have all their care needs, including their social and emotional needs assessed prior to admission. Any concerns noted regarding the resident at the point of assessment and admission had to be documented and investigated. Care records were assessed that provided evidence that these requirements were being met. However continued effort is needed to identify the recreational and social interests and activities of prospective residents before and after admission. All information should be recorded to inform staff and contribute to the individual’s care plan. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not fully assessed during this inspection. However compliance with the requirements set in the previous report was checked. Requirements were made that the social and emotional needs of the residents must be recorded on their care plans and their daily records should reflect how they were being met. When residents displayed distressed and unsettled behaviour this needed to be reflected in their care plan. Photographs of residents needed to be kept on their care files. The care record assessed provided evidence that resident’s emotional needs were identified in their care plans with strategies to restore their well being. Records also contained the required photographs. However in the care plan that was assessed there was no information regarding personal recreational interests and social and family connections and supporters. Therefore this requirement will be repeated in this report. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 10 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 Residents are able to exercise control over their lives within their abilities and make choices and decisions on matters that affect them. EVIDENCE: Residents’ records and discussion with the manager confirmed that residents were able to make choices and decisions regarding their care and lifestyles. Conversations with the residents confirmed that they felt able to express their opinions and make requests. Meetings were regularly held with the residents and their relatives. A programme of activities was displayed in the entrance to the home and residents were aware that there was an activities organiser. It was apparent that they appreciated and enjoyed the opportunities and support that she provided. It was suggested that the programme be produced in larger print and distributed more fully around the home, taking care to include those people who preferred to stay in their rooms. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 11 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): EVIDENCE: These standards were not fully assessed during this inspection. However compliance with the requirements set in the previous report was checked. Requirements were made that all complaints from residents and relatives must be recorded and any action taken clearly documented. All staff must be made aware of their responsibilities in the protection of vulnerable adults and it was recommended that the complaints procedure should be known and made accessible to all residents. Records were seen containing two complaints that were being addressed by the manager and her line manager. The manager confirmed that all documents arising out of the concerns would be appropriately filed. A copy of the complaint procedure was contained in the Statement of Purpose and the Service Users’ Guide. A copy was also displayed in the entrance to the home. The manager confirmed that all residents received a copy of the Service Users’ Guide when they were admitted and she regularly spoke to the residents and ensured that they knew who she was and that they could approach her or any staff with any concerns. Reminders were also given during residents and relatives meetings. Residents and a relative confirmed that they had no complaints at the time of the inspection and would raise any issues that concerned them. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 12 The manager confirmed that all staff had read the policies and procedures concerning the protection of vulnerable adults. In the past they had raise matters that had concerned them. The manager said that formal training relating to the Protection of Vulnerable Adults was being arranged for all staff. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 13 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): EVIDENCE: These standards were not assessed during this inspection. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 14 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): 28, 29, 30 Suitable staff are recruited and trained to provide an acceptable standard of care for those who live in the home. EVIDENCE: The staff team included 32 care staff. The manager said that 10 of these people were qualified to NVQ level 2 and a further 6 people were awaiting an assessment date. The organisation now employed two designated trainers who were responsive and supportive in assessing training needs and developing suitable training programmes. The records of one staff member were assessed and were acceptable. The records demonstrated that staff received induction training when appointed and continued to receive training during employment. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 15 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): 33, 35 38 Quality is continuously monitored to identify needs and improve the service. Residents are supported in the management of their personal monies. Health and safety is addressed to provide a safe environment for those people in the home. However First aid and fire safety knowledge and skill needs to be increased. EVIDENCE: At the time of the previous inspection there were concerns regarding the management of the home in the absence of the registered manager. These concerns were addressed and the manager has now returned to duty. The staff and residents expressed their pleasure at her return. The staff supervision programme was not being maintained. However this has now been rectified. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 16 The quality assurance standard was assessed. A good audit programme was in use that covered many of the systems. Reports were raised each month by the provider’s representative in accordance with regulation 26. A range of questionnaires was distributed and responses analysed and actioned to continuously identify needs and improve the service. All policies and procedures had recently been reviewed. Residents who lacked the ability or wish to manage their own personal finances were assisted by the home. It was observed that there was acceptable storage and records were well maintained. Staff received training on topics relating to health and safety. However the frequency of training in fire safety needed to be increased. Fire safety training was being given twice a year. The guidance provided by the Hereford and Worcester Fire Authority is for quarterly training in care homes. A training matrix and monitoring tool were discussed and various ways in which the training could be given to a large work force at the frequency required. Five of the staff had done the one-day first aid training to be appointed persons and eight people were booked onto the course on the 1st of March. This one-day course does not qualify anyone as a first aider. A qualified first aider (some one who has successfully qualified on the four day first aid at work course) should be on duty at all times. Health and safety was being addressed in the home and relevant risk assessments had been drawn up and were available. The manager said that there was a policy and procedure kept in the administrator’s room and was available to all staff. Accident records were maintained and regularly analysed for trends. Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 17 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 3 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The social and emotional needs of the residents must be recorded on their care plan and daily records must reflect how they are being met. Fire safety training must be provided for all staff every three months in accordance with the guidance provided by the Hereford and Worcester Fire Authority. A first aider (four day First Aid at Work Qualification) must be on duty at all times. Timescale for action 01/03/06 2 OP38 23 14/04/06 3 OP38 13 14/09/06 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 Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Bowood Court Nursing & Residential Home DS0000004096.V281456.R01.S.doc Version 5.1 Page 20 - 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. 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