Inspection on 14/07/06 for Bowood Mews

This inspection was carried out on 14th July 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 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 31/01/06

Bowood Mews 10/07/05

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 Chris Potter Unannounced Inspection 14th July 2006 09:00 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 Mews DS0000018485.V304375.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. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bowood Mews Address Hewell Road Redditch Worcestershire B97 6AT 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) 01527 60029 01527 592750 www.schealthcare.co.uk Southern Cross Healthcare Services Limited Mrs Susan Dianne Parkinson Care Home 34 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (34) of places Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 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. 31st January 2006 Date of last inspection 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. The fees for this service are between £383.00 to £441.00. Hairdressing, chiropody, newspapers and costs towards outings are not included in the fees. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was Bowood Mew’s key unannounced inspection. The inspection took place on the 14th July 2006 and lasted a total of six and a half hours. The last inspection of Bowood took place in January 2006. The inspection focused on the environment, residents care delivery through case tracking and their care documentation, staffing. The views of the residents and relatives were sought at the time of the visit. Feedback received from relatives was generally positive about the homes provision. What the service does well: What has improved since the last inspection? What they could do better: Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 6 The home must adhere fully to their staff recruitment policy. Several comments received about the food stated that it was variable. The laundry provision should be reviewed to improve the service. The home must ensure all staff are appropriately trained to meet the care needs of the residents. 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 DS0000018485.V304375.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 Bowood Mews DS0000018485.V304375.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 The outcome for this area is good. This judgement has been made using the available evidence including visits to this service. The home provides prospective residents and relatives with appropriate information and advice to assist them in making their choice about the home. The manager assesses all residents prior to admission to ensure the home can meet the assessed needs of the resident. EVIDENCE: A copy of the homes Statement of Purpose and Service User Guide was available for all residents and relatives to view. A copy was available in reception and in the resident’s bedrooms. The home also provides their Service User’s Guide in audio to assist residents with sight problems. The information needs to be updated to reflect resent staff changes. Relatives spoken to at the time of the visit confirmed they had been provided with the relevant information to assist them in choosing the home. They had also been invited to view the home and meet the staff. The home provides all residents with a contract of terms and conditions on admission to the home. Copies of which are available at the home. The Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 9 manager carries out a pre-admission assessment for every potential resident to ensure the home can meet there assessed needs. Three residents care records reviewed at the time of the inspection had copies of the pre-admission assessment included. This forms the basis of the residents care documentation. Bowood Mews DS0000018485.V304375.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,and 10 The outcome for this area is good. This judgement has been made using available evidence including visits to this service. Care plans and risk assessments are reflective of the resident’s care needs. EVIDENCE: Three residents care files were reviewed at the time of the inspection. These evidenced that the home had carried out appropriate risk assessments on the residents. From the risk assessment the staff had developed care plans appropriately reflecting the residents care needs. Feedback from relatives stated that the home was providing good care. A comment received stated “I have always been impressed with the care and attention given by the staff to residents in their care at Bowood Mews.” Staff were able to express the knowledge and understanding of the residents care needs. The home has a good relationship with the district nurses and maintains records of their visits. Staff were observed tending the residents care needs in a dignified manor. There was good interaction between staff, residents and relatives, which gave a pleasant atmosphere. Since the last inspection senior care staff have undertaken medication training, the pharmacist provides good support to the home. The management of medication at the time of the visit was commended. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 11 Bowood Mews DS0000018485.V304375.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The outcome for this area is adequate. This judgement has been made using evidence including visits to this service. The opportunities for residents to partake in activities are satisfactory. The dietary needs of residents are limited, and little choice is available. EVIDENCE: The food is cooked in the sister home opposite and the food is transported through the grounds in heated trolleys. Comments received prior to inspection and during the inspection expressed that the food quality is variable with limited choice. Residents confirmed that they were provided with a choice of meals for breakfast, dinner and tea. The residents confirmed that the meal sizes was more than sufficient. On the day of the inspection the lunch was soup, followed by fish, chips and mushy peas. The alternative to fish was egg with chips followed by a packet bakewell tart and custard. The meal appeared over cooked and dry. Residents stated they had not enjoyed the meal. The need to review the quality of food is required and the home must monitor this carefully. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 13 Relatives are able to visit at any time and can also have their meals. This was confirmed from feedback and relatives who were visiting at the time of the inspection. The home is able to provide meals for specialist diets; none are being catered for at the moment. The home employs an activities organiser covering twenty hours per week, and a programme of activities was displayed in the home. Details of social activities were also included in the residents care records. On the day of the inspection the activities organiser was off duty. Appropriate music was being played around the home. Some residents were reading their newspapers. Activities provided include outings to shops, craft centres and garden centres. The deputy manager confirmed that the residents tend to cope better with shorter outings rather that full days. A resident showed the inspector the enclosed garden and the flowering pots, which she had helped to plant. The deputy manager discussed future plans to develop the garden allowing easier access for the residents. The maintenance operative has built a garden table so residents are able to sit out when the weather permits and enjoy the sunshine. Feedback from some relatives about the home stated they would like to see more activities within the home. Bowood Mews DS0000018485.V304375.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The outcome for this area is adequate. This judgement has been made using available evidence including visits to this service. There is a complaints procedure in place. A vulnerable adults procedure is in place to ensure a proper response to any suspicion or allegation is carried out. EVIDENCE: The home has a complaints policy in place. The complaints records were reviewed at the time of the inspection and these showed that the home had received two complaints since the last inspection. No complaints have been received by the CSCI in respect of this service since the last inspection. The complaints were in connection with the laundry, and clothes going missing. Relatives and staff spoken to confirmed that it is a continual problem with clothing not returning from the laundry. The home should monitor this situation closely. Feedback received from relatives confirmed that they were aware of the complaints procedure. A relative spoken with during the visit confirmed that the home had responded appropriately to a complaint they had made. Since the last inspection the home has had two incidents, which were referred, by the home for investigation under the protection of vulnerable adults. The home has maintained clear documentation and this was available at the time of the visit. The home had acted appropriately and adhered to their policy. All staff receives training in recognising potential abuse to vulnerable adults. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 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): 19,20,21,22,23,24,25 and 26 The outcome for this area is good. This judgement has been made using available evidence including a visit to this service. The home provides a pleasant well-maintained environment for the residents to live in. EVIDENCE: The home is purpose built and provides single bedroom accommodation for the residents, the home is well maintained and in reasonable decorative order throughout. The lounge areas appearance would be further enhanced by a redecoration program. The home assists residents with short-term memory impairment by using colour-coded themes. This assists the residents to locate their bedrooms, toilets and bathrooms easier. The home has a passenger lift so residents with mobility problems can access all areas of the home. Many of the bedrooms have been personalised by the resident to reflect their personality. During the visit residents showed they were clearly pleased with their bedrooms and the way they are furnished. The home has provided air conditioning units to assist in maintaining a comfortable temperature for the residents and staff. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 16 All residents had drinks and jugs of squash were available in the lounges. Some odours were evident on the first floor; it was recommended that a more industrial type-cleaning machine be reviewed. It was also noted that only one house- keeper was cleaning the whole of the home on the day of the visit. Given the high percentage of residents with continence problems this should be reviewed. It was observed during the visit that a resident had returned to their bedroom and faecally soiled the carpet, chair and bed. This was at approximately 1pm, when the housekeeper had finished, leaving care staff to clean the room. The laundry for the home is undertaken by the sister home in the same grounds from feedback discussion with relatives and staff, it was reported that this is an unsatisfactory process with clothes going missing and families making complaints to the home; it is recommended that this is reviewed and monitored to provide a more effective service. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 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): 27,28,29 and 30 The outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are within the minimal recommended levels for the number of residents. The home must adhere to their recruitment policy. EVIDENCE: The duty rotas for the home were reviewed. Presently the home is having difficulties covering shifts due to staff sickness and maternity leave. The Deputy manager acknowledged that staff are being very helpful and working additional hours. Where they are not able to cover agency staff are being used. The home requests the same agency staff to ensure consistency for the residents. A copy of the staff-training matrix was provided and forth coming training to be provided, was given, it was noted that gaps with mandatory training were evident for some staff. The home must ensure that all staff receive and are updated with the training to assist them in meeting the needs of the residents fully. The requirement for fire training and a qualified first aider to be on duty for the 24-hour day as been actioned. Three staff files were reviewed during the visit and identified that the home does not keep a copy of their CRB record, which is required for the first Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 18 inspection after the member of staff, has been appointed. The home also must ensure that the applicant provides a full employment history and any gaps are explained fully. The home has an equal opportunity policy in place and staff are advised of this. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 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): 31,32,33,34,35,36,37 and 38 The outcome for this area is good. This judgement has been made using available evidence including a visit to this service. The manager is competent to ensure the needs of the residents are met. Records are well maintained to provide information and guidance. Regular servicing and monitoring of equipment reduces environmental risk. EVIDENCE: The manager and deputy manager have the knowledge and experience to manage the home. The manager has worked at the home for many years and completed the Registered Manager’s Award. The deputy manager was appointed three weeks ago, but has worked at the home as a senior carer prior to this. The deputy manager assisted throughout the inspection and managed very well. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 20 Feedback from residents, relatives and staff confirmed that the manager and deputy are approachable and always available to answer questions. The home holds staff and relatives meetings and the minutes of these are available at the home. The home conducts regular audits and surveys about the quality of the service they provide. The Responsible Individual provides CSCI with a regulation 26 reports every month. The manager undertakes regular supervision sessions with the staff; copies of these were available at the time of the inspection. Resident’s finances are not held by the home. The home manages petty cash only for hairdressing and newspapers. Records are maintained and the amounts are checked weekly by staff to ensure the amount is correct. Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 3 3 3 3 3 Bowood Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 4 Requirement The statement of purpose must be updated to include all information as specified in Regulation 4 (1) Schedule 1 Timescale for action 14/09/06 Remains outstanding from last inspection. 2 3 4 OP1 OP15 OP15 4 16(2)(i) 16 (2) (i) The Service User’s Guide must 14/09/06 be updated to include all information as specified. Food provided for residents 21/07/06 should be presented in an appetising manner. The home should monitor the 30/07/06 quality of food being provided for the residents and deal with this appropriately. Staff must not work excessive hours. This must be monitored by the home. 5. 6. OP27 OP26 18(1) 13 30/07/06 30/07/06 7 OP26 13 8 OP30 18 (1) The home must investigate the source of the odours, and review the hours allocated for the cleaning of the home. The laundry provision for the home must be improved and monitored to reduce the residents losing their clothes. The home must ensure that all staff have received and receive regular updates with mandatory DS0000018485.V304375.R01.S.doc 30/07/06 30/07/06 Bowood Mews Version 5.2 Page 23 9 OP29 18 (1) training. The home should be able to evidence that the CRB has been undertaken and provide this for the inspection. Any gaps in the employment history must be fully explained. 30/07/06 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 Mews DS0000018485.V304375.R01.S.doc Version 5.2 Page 24 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 Mews DS0000018485.V304375.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!