Inspection on 10/07/05 for Bowood Mews

This inspection was carried out on 10th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bowood Mews 17/09/08

Bowood Mews 13/11/07

Bowood Mews 14/07/06

Bowood Mews 31/01/06

Bowood Mews 31/01/05

Bowood Mews 23/08/04

Bowood Mews 23/02/04

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

CARE HOMES FOR OLDER PEOPLE Bowood Mews Hewell Road Redditch Worcestershire B97 6AT Lead Inspector Annie OMara Unannounced 10 July 2005 3:00 pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bowood Mews Address Hewell Road, Redditch, Worcestershire B97 6AT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01527 60029 01527 59270 Southern Cross Healthcare Services Limited Mrs Susan Dianne Parkinson Care Home 34 Category(ies) of DE Dementia (3) registration, with number DE(E) Dementia over 65 (34) of places Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. the home is primarily for people over the age of 65 who have a dementia illness but may accommodate people who in addition have a physical disability. Date of last inspection 31 January 2005 Brief Description of the Service: The home provides personal care for up to thirty-four older people with dementia. Within that number there are three places registered for younger adults with dementia. Bowood Mews is situated within ½ a mile of Redditch Town centre. It is a purpose built building and all bedrooms are single ensuite. The home is on two floors which are staffed separately. There is a lift to the first floor. There is a secure garden.It shares laundry and kitchen facilities with Bowood Court, both of which are on the Bowood Court premises. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Sunday afternoon/evening. Care records were examined, all members of staff on duty were spoken to and two residents were asked for their opinion about the home. Due to the specialist needs of the residents information provided by them was limited. The quality assurance system in place had also been inspected. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments for residents should be more regularly reviewed to help keep everyone in the home safe. The rotas must not encourage or allow staff to work long hours as this is not good for them or residents. Rotas must be checked to ensure that there is a senior on duty at all times. More attention could be paid to the cosmetic décor of the home to ensure it is comfortable and homely. A recommendation made previously about having a member of staff start at 7.00 am has disappointingly not been actioned. This was to ensure that residents are appropriately supervised early in the morning. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 6 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 Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, The home provides information to help residents and their representatives make an informed choice about moving into the home. The assessment process is thorough ensuring that residents needs are understood at the point of admission. EVIDENCE: Information about the home and the services they offered is available to prospective residents and their representatives. Some of the information is out of date and needs some minor changes. Assessments are undertaken for each resident prior to them moving into the home to ensure their needs can be met. Additional information was available from previous placements. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 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 standard(s) 7, 8, 9, Care planning in the home ensures that residents needs are understood, and that staff are aware of how these needs are to be met. The risk assessment process needs to be developed to ensure that all residents are kept safe within the home. EVIDENCE: The care plans in place for the residents are comprehensive, showing care needs and how these will be met. Regular reviews are held. Health care issues are monitored and the primary health care team consulted as necessary, and including more specialist services. The majority of the risk assessments seen were appropriate and up to date. One risk assessment for a resident who had some challenging behaviours had not been updated, did not show the risks to other residents nor had it been signed by the residents’ representative. This information had not been passed to the Commission for Social Care Inspection as required on every occasion. Additionally, a particular behaviour rating scale used by the home had not been accurately filled in. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 10 The medication administration in the home is well managed. There was a concern about a senior member of staff not being available in the home to administer any medications which are given as needed during the night on one occasion. During the inspection staff were observed speaking to residents with warmth and respect. Residents were given choices by the staff and actions were explained to them as appropriate. A resident who was spoken to confirmed that staff were kind to her. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 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 standard(s) 15 The food provided does not always take into account the specialist needs of the residents and is not appealing in its presentation. EVIDENCE: The menu on display was for the previous day. It was in small type and kept in part of the home which would not be visited by all residents. Not all of this standard was assessed. However the teatime meal was seen and the food prepared for people who needed soft diets looked very unappetising. Staff said that the soft diets did tend to look colourless and unappetising. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Complaints are thoroughly investigated and documented although outcomes do not always protect the residents appropriately. EVIDENCE: There was a complaints procedure in place which provides the necessary information for people to complain, although the name of the person to be contacted has since left the company. There was a record kept of complaints made and any actions taken which shows that complaints are taken seriously. The Commission for Social Care Inspection has received one complaint about the home in regard to the management of a staffing disciplinary matter. This is being taken up separately to this report with the operations manager of the home to discuss the outcome of the investigation. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 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 standard(s) 19, 21, 25, 26 Although the home was generally well looked after and residents are not at risk, some attention needs to be paid to the cosmetic appearance of some areas to maintain the comfort of the home. EVIDENCE: The home was generally well maintained and clean. The carpet in the upstairs dining room and corridors were stained and there were some areas of paintwork throughout the home which was scuffed. Some small pieces of wallpaper were ripped. The deputy manager did say that carpets had been ordered to replace existing ones. Residents were enjoying the sunshine in the secure gardens where seating and a gazebo had been placed. Toilets visited were clean although not all of them had gloves available for hygiene purposes. Staff had received infection control training and were seen to carry out good hygiene practices. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 30. Arrangements for staff cover put the residents in a position of risk and failed to safeguard their needs, and placed staff and residents in a position of vulnerability. The training in place continues to support the staff in their work so that they are competent and able to keep the residents safe. EVIDENCE: The main issue from this inspection was in relation to staffing during the night preceding the inspection. Rotas indicated that there had been no senior on duty, and two of the three staff members had not been employed at the home for very long. There had been an incident at the home during the night which had been dealt with appropriately but had put the residents and carers in a vulnerable position. There had also been issues about the senior on call not being reached, and there were implications for residents who required medication during the night. The rotas indicated that there was no senior on shift for the following night. The on call senior was contacted and senior cover arranged during the inspection. Staff had also worked excessive hours including a day shift followed by a night shift and then an afternoon shift. This practice is totally unacceptable. Immediate Requirements were left in respect of this matter. Following a previous concern raised in the home it was recommended that a member of day staff starts their shift a t 7.00 am instead of 8.00 am to provide adequate supervision to residents whilst night staff are helping them to get up. This has not been done and does place residents at risk. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 15 Staffing records were not examined but recent training had included induction training, infection control, first aid and food hygiene. Three of the four staff spoken to were either undertaking or had achieved their NVQ training. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The home operates a fair and honest system for reviewing their performance to ensure that residents’ welfare is protected EVIDENCE: The homes quality assurance program indicated that staff training was regularly monitored and that health and safety issues were regularly reviewed and monitored. Relative and residents questionnaires had been sent out and the majority stated they were happy with the service received. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 3 x x x x 2 STAFFING Standard No Score 27 1 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x 3 x x x x x Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 18 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 1 Regulation 4 Requirement The statement of purpose must be updated to include all information as specified in Regulation 4 (1) Schedule 1 Risk assessments in relation to residents challenging behaviours must be in place and include any risks to other residents. Timescale of 31st March 2005 not met. Risk assessments must be regularly reviewed and updated when residents needs change. Timescale of 31st March 2005 not met. Senior staff must be available at all times to administer medication. Food provided for residents must be presented in an appetising manner. The carpets in the dining rooms and corridors must be replaced. Gloves must be made available in all toilet areas. A senior member of staff must be on duty at all times during the night. Staff must not work excessive Timescale for action 30th September 2005 14th August 2005 2. 8 15,13 3. 8 15,13 14th August 2005 4. 5. 6. 7. 8. 9. 9 15 19 26 27 27 23(1) 16(2)(i) 23(2) 13 18(1) 18(1) Immediate 14th August 2005 30th September 2005 14th August 2005 Immediate Immediate Page 19 Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 hours. 10. 37 17(1) Schedule 3 All incidents of aggressive behaviour must be reported to the Commisiion for Social Care Inspection. 14th August 2005 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. 2. Refer to Standard 15 27 Good Practice Recommendations The written menu should be in an appropriate format for the residents to understand. Consideration should be given to the introduction of a member of staff starting work at 7.00 am to ensure that residents are supervised appropriately. Bowood Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 20 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 Mews E52 S18485 Bowood Mews V236225 100705.doc Version 1.40 Page 21 - 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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