Inspection on 17/09/08 for Bowood Mews

This inspection was carried out on 17th September 2008.

CSCI found this care home to be providing an Good service.

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

Bowood Mews 13/11/07

Bowood Mews 14/07/06

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 05/12/2008.

CARE HOMES FOR OLDER PEOPLE Bowood Mews Hewell Road Redditch Worcestershire B97 6AT Lead Inspector Chris Potter Unannounced Inspection 17th September 2008 09:15a 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.V371866.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.V371866.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 bowoodmews@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Ltd 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.V371866.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. 13th November 2007 Date of last inspection Brief Description of the Service: Bowood Mews is a purpose built home providing 24 hour care for up to 34 older people with a dementia type illness. The home is conveniently situated within ½ a mile of Redditch town centre, which is convenient for visitors using public transport. All residents are accommodated in a single bedroom with en-suite facilities. The home is on two floors with a passenger lift to assist residents with mobility problems to access all areas of the home. The home provides communal lounges, dining rooms, quiet areas and specialised bathrooms. There is a pleasant landscaped garden with raised flowerbeds for the residents to use and enjoy when the weather permits. It shares laundry and kitchen facilities with Bowood Court, both of which are on the Bowood Court premises. Information regarding the home can be obtained from the statement of purpose and the service users’ guide, which are available from the home. The home belongs to Southern Cross Healthcare, which is a large organisation that own homes all over the country. The registered manager is Sue Parkinson who has been in post for several years and possesses the recognised manager’s qualification The weekly fees for this service at the time of the inspection ranged from £353.00 to £469.66. For up to date information please contact the home direct. The fees do not include Hairdressing, chiropody, newspapers and costs towards some transport. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. We, the commission undertook an unannounced inspection of this service over one day. This was a key inspection – this is an inspection where we look at a wide range of areas. Before the inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the service for completion. The AQAA is a self-assessment and a dataset that each registered provider has to complete each year and send to us within agreed timescales. The document tells us about how providers of services are meeting outcomes for people who use the service and is an opportunity for them to share with us what aspects of the service they believe they are doing well. Some of the provider’s comments have been included within this inspection report. During the visit to the home care records, staff records and other records and documents were inspected. Surveys were sent out and received from residents (four), staff (two). There was a tour of parts of the accommodation and interviews with staff and relatives available on the day. Time was spent speaking privately with residents. What the service does well: The home is well maintained, attractively decorated and furnished. The home uses specialist guidance for the resident group with promoting colour themes and signs to assist the residents in finding their way around the home. Bowood Mews has a dedicated team of staff who address and care for residents’ in a sensitive manner, which ensures their privacy and dignity, is maintained. We were told this by residents and relatives and the home’s customer satisfaction feedback. Residents told us they are provided with a varied diet and are consulted regarding food preferences and choice of menu. Residents are able to eat in the dining room or in the privacy of their bedroom. We looked at the management of medication and found the system to be well organised, and the carers following the home’s policies and procedures. The activities person is enthusiastic, and provides entertainment and social activities individualised to the persons’ wishes and their capabilities. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 6 We received positive feedback about the home’s facilities and the staff, comments included: “we are made to feel welcome at any time when we visit, and that the staff keep us informed of any changes in ----- condition”. “we are provided with a choice food and generally it is good” “I like my bedroom it is a good size, with a television” “Like one big family” “staff always willing to assist her nothing is ever too much trouble” “We have regular meetings and a newsletter to advise what is happening” “ --- is always dressed smartly” “I feel like part of the care” “I cannot find the words to describe what a wonderful home” The home is clean and tidy and the management of odours is generally good. Residents are able to bring some of their own personal possessions into the home. What has improved since the last inspection? The gardens have been landscaped with raised flower beds so that the residents who wish can have a go. Other residents can enjoy the gardens for sitting in when the weather permits. Management of medication had improved from the last inspection. Where the home were required to ensure that all staff maintain accurate recording on the residents medication administration record to reduce the potential for any possible errors. The information in the residents care plans have improved, and are now more person centred and includes the resident and relatives with the development. Information including the homes’ statement of purpose and service users’ guide for people enquiring about the service, and for residents’ and their families to refer to had been reviewed and updated. With the addition of extra domestic hours, the management of odours has improved, providing a more pleasant environment for the residents. Deleted: . What they could do better: The inspection did not identify any shortfalls or make any good practise recommendations. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 8 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.V371866.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3 (standard 6 is not applicable to this home) Quality in this outcome area is good. People who are considering using the service have access to information they need to make informed choices, and they can be confident that the care home can meet their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw copies of the home’s Statement of Purpose and Service User Guide in the reception area of the home and a copy of the Service User Guide was seen in residents’ bedrooms. The Service User Guide and Statement of Purpose had been updated since the last key inspection. The manager told us that the Service Users’ Guide is also available in audio format to assist the residents’ with sensory impairments. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 10 Surveys received from resident’s using the service confirmed that they were provided with sufficient information to assist them with their choice of home. Relatives told us that they had been provided with sufficient information about the home to assist them with their choice. Comments received included the following: “I like my bedroom it is a good size, with a television” “I cannot find the words to describe what a wonderful home” “my --- has settled really well, nothing is too much trouble for the staff, and they make me feel welcome and included in --- care” We looked at three people’s pre-admission assessments, which had been completed before they moved into Bowood Mews. The manager told us she completes pre – care needs assessments, which provides basic information for the staff before the person moves into the home. The assessment assists in determining whether they are able to meet the health and personal care needs of the individual. The assessments’ were clear and contained sufficient information for the home to develop a plan of care based on the initial assessment. The assessment showed that the person and their relatives had contributed and agreed to the contents. Surveys received before the inspection confirmed that they people had been assessed, before they decided to move into the home. The Annual Quality Assurance Assessment completed by the manager indicates is reflective of how the home is meeting these standards and haw the home is aiming to improve the service over the next 12 months. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is good. The resident’s health and personal care needs are met. All residents have a plan of care that, where possible, the person or someone close to them has been involved in making. The home supports the residents with their medication in a safe way. Resident’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care records for three residents, and these showed that the care records had been agreed with the person or, if appropriate, their relative. The record provided clear information as to why the resident needed residential care. The record also provided details of how the home was meeting the health, welfare and psychological needs of each person. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 12 Appropriate risk assessments had been completed on admission, which provide a baseline in monitoring the individual’s health. From the risk assessment, a plan of care had been developed to direct carers in minimising any potential risk. This also enables the carers to identify any changes that may need additional resources an example being assessed by the diabetic nurse for advice about the management of the resident’s condition. We looked at the care records for a resident with diabetes, which provided clear guidance for the carers on how to monitor the person and provided information about the condition. The resident was receiving a diabetic diet, and medication to manage their condition, and we were told this was being well managed. For another resident who can be difficult due to their stage of dementia the care plan gave clear guidance for the carers to follow when this occurred. The care records included a comprehensive “social history” about the person providing information about their childhood, family, employment and hobbies. This assists the staff in getting to know the residents, and provides some insight about likes and dislikes. The carers are recording meaningful daily statements about the person and the care provision. The deputy manager has prioritised on producing care records that accurately reflect the individual. Relatives told us that they had been involved in the care plan development and given feedback when needs changed. We received positive feedback from residents’ using the service and their relatives. Comments received included; “the home is excellent” “staff are very wonderful” “staff always willing to assist her nothing is ever to much trouble” “I do not mind male or female carers, but they do give me a choice” “ – always appears smart and well cared for” We saw residents walking around the home, and all appeared appropriately dressed and content. All staff in the home were interacting positively with the residents, and relatives providing a relaxed and friendly atmosphere. The environment is themed at assisting residents with short-term memory, using colour themes, signs, pictures and photographs to assist the residents in finding their way around the home. The deputy manager has been nominated for the “carer of the year award”, and wonderful comments have been received about her and her dedication to the home and residents. Comments included: Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 13 “totally dedicated” “exceptionally caring nature” “makes time for the family” “the love and care was always there, no matter what time of day we visit” We looked at how medication was being managed for the three residents and found the system to be well organised. For example the medication prescribed for the resident with diabetes was being administered at the correct times and their were no gaps on their medication administration record. A copy of the original prescription was available to check that the details on the medication record were correct. A record of who administers the medication is held and used to assist the monthly quality audit. The medication administration records seen were well documented with no gaps on the record. The balance of medication was correct for those residents checked. Which shows medication is being well managed and residents can be confident staff practices promote and maintain their health and welfare. We observed staff respecting residents’ privacy and dignity - for example, knocking on doors before entering private rooms, and speaking to them courteously. Residents and relatives told us that staff are respectful and courteous when addressing them. 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. JUDGEMENT – we looked at outcomes for the following standard(s): Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 14 Standards 12,13,14 and 15 Quality in this outcome area is good. The provision of social and recreational activities for residents has improved and is now more person-centred depending on the residents’ needs. People keep in touch with family, friends and representatives. They are as independent as can be. People have nutritious meals and snacks, at a time and place to suit them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a very enthusiastic activities organiser who covers 25 hours over the week, including some evenings and weekends. She has developed a good rapport with the residents by getting to know them and developing a detailed social assessment of the individual including their likes and dislikes. She provides one-to-one individualised time for them, goes round residents depending on their capabilities, and performs hand massage, which assists in relaxing the resident. Other residents prefer to join group activities and their art and craftwork is displayed around the home. Some residents were making placemats and were proud too show these to us. The home has many photographs displayed around the home of the events which the residents have participated in. The activities person maintains individual records advising what activities if any, the resident has participated in. The records seen by us also include a record about the residents’ visitors. The activities organiser told us there is an allocated budget for activities. Recent trips have included the botanical gardens, and pub lunches. Regular church services are held for the residents who wish to attend. Comments received from the residents and relatives about the activities included; “The activities are fairly good”. “I prefer not to join in, but they are available if you wish to.” “Sue is wonderful” The manager told us that they try to protect meal times so that residents are not disturbed by doctor’s visits, and all staff can focus on assisting the Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 15 residents with their food. The manager sits with the residents at various meal times to sample the food and socialise with the residents. The home facilitates residents’ wishes. For example on the day of the inspection, a resident was being accompanied to visit another resident who was in hospital A relative told us that regular relatives’ meetings are held and a newsletter to keep them up to date with what is happening in the home. Residents and staff told us that the quality and choice of food was good. The chef confirmed that the menus have been reviewed since the last inspection, offering the residents a more varied choice. Residents were observed in the dining room being served lunch. The dining room is attractive and with the use of decoration and displays assists residents with short-term memory loss. Staff were observed prompting residents to eat in a respectful way. The manager also sits with the residents at various times to test the food and further monitor the residents. Comments about the food included; “we are provided with a choice food and generally it is good” “good home cooked food” “some meals can be a little bland” “would prefer a little more spicy food” “my only complaint, I have gained weight” A relative spoken with advised us of a complaint they had made to the organisations area manager, about the carers’ having to manually wash up, she feels that this is unfair given the amount of work they do. They had not received a response to this at the time of the inspection. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. Residents who use the service are able to express their concerns and have access to the home’s complaints procedure. Bowood Mews safeguards the residents from abuse and neglect and encourages all staff to raise any concern so that the residents are further protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We have received no complaints about this service since the last key inspection in November 2007. The home’s complaints procedure and records were seen. These showed that the home was following their complaints policy. The home has received four complaints directly and the details of these and the outcome of the home’s investigation were appropriately recorded in the register. The manager and deputy manager make themselves available for visitors who referred to both by their first name. Residents and relatives spoken with were aware of the home’s policy and who to report concerns to. Comments from people using the service included: Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 17 “I have no complaints” “I have made a complaint to the head office, because I do not feel it is right that the carers’ are washing up manually after the meals, they have more than enough to do!” Staff told us they had received “safeguarding” training and were aware of the home’s whistle blowing policy. Staff also confirmed that they would have no hesitation in reporting any concerns to the manager. The Annual Quality Assurance Assessment completed by the manager stated that plans for improvements over the next 12 months include ongoing and further training in Abuse awareness, protection of vulnerable adults, whistle blowing and the mental capacity act. The organisation (Southern Cross) has launched a national helpline in partnership with Action for Elder Abuse to increase their profile on abuse prevention. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good. Residents stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Bowood mews is a purpose built two storey care home set in close walking distance to the Town centre of Redditch, close to the train station and local bus routes. Bowood Mews provides accommodation for up to 34 older people with a degree of dementia requiring personal care and support. All bedrooms are single with en-suite facilities. Communal areas of the home include two Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 19 lounges, two dining rooms, specialist baths that can be used for people with mobility problems and an enclosed landscaped garden. A passenger lift is available and used to assist residents with limited mobility to access all areas of the home. To assist residents to find their way around the home, various colours and themes are illustrated. The themed areas display the craftwork completed by some of the residents, and create quite a feature for the home. Residents were observed walking around the home quite happily and were proud to show us their rooms. The garden was well maintained; the manager told us that some of the residents are helping through their activities to look after the plants. The home arranged for a specialist in dementia care to visit the home to see if they could further improve the environment for residents. Some of the recommendations suggested have been implemented and the manager and staff were monitoring the residents to establish how beneficial the changes are for them. For example near the entrance, a selection of hats and a mirror have been placed and are used by the residents to reflect their image. We looked at some of the residents’ bedrooms and these were personalised for the individual with ornaments and pictures. The manager told us that since the last inspection the home has replaced the carpets in the lounges, which further improve their appearance. All areas of the home were clean and tidy, by increasing the domestic hours for the home the odours have been addressed, which were reported at the last key inspection. The Annual Quality Assurance Assessment completed by the manager stated that the improvements in the last 12 months included the development of a sensory room. This is a quiet area of the home with quiet music and a comfortable seating area for residents to relax in. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good. Residents’ can be confident that their needs will be met by sufficient numbers of appropriately trained and qualified staff. Residents benefit from robust staff recruitment practices that ensure only suitable people are employed at the care home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the home’s duty rotas, which confirmed that the home is providing sufficient staff proportionate to the number of residents and their care needs. The manager told us that the home have a stable staff team and never use agency staff, any shortfalls in the staff roster are covered with their own staff. Residents’, relatives’ and staff told us there are enough staff available. Staff stated that the only exception to this was when staff went off sick at short notice. We observed staff responding promptly to residents when they asked for assistance. All staff in the home were observed interacting well with the residents and this provided a friendly atmosphere. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 21 The home has achieved the standard for providing 50 of care staff with a National Vocational Qualification (NVQ) level two or above. On the day of the inspection, the manager was conducting interviews for a care assistant. One resident was participating in the interview. The manager told us this assists her in monitoring how the applicant interacts with the resident. We looked at the personnel record files belonging to three staff members and records showed that the home had carried out all the appropriate security checks before the staff had started working at the home. The home employs male and female staff from a diverse cultural background, and respects the preferences of the people using the service for male or female staff. We were showed the training matrix maintained by home to assist them in ensuring that staff receive appropriate training and refresher courses when required. All staff receive training with how to meet the needs of their residents and in particular various types and stages of dementia. Relatives told us that the staff are knowledgeable and provide them with the support they need in coping with their relation. Residents told us that they are confident that the staff have the knowledge to meet their needs. The manager told us that the deputy manager has completed a training qualification at college and is now able to assist staff with their training and assess their needs. Comments received from relatives included; • • • • “Compliments to all staff with grateful thanks for all the care”, “Staff are excellent”, “they make me feel part of the care” “Staff respect our privacy”. The Annual Quality Assurance Assessment completed by the manager was reflective of these standards. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,and 38 Quality in this outcome area is good. Residents can be confident they will receive the support they need and will feel valued and respected as an individual, because the home is managed in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents, relatives and staff told us that the manager and deputy manager are “both wonderful”. The manager has completed the registered manager’s qualification and has many years experience of caring for residents with a dementia type illness. The deputy manager has completed an NVQ level 3 and has completed a training course known as “PETALS” which assists her in Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 23 delivering training to care staff. Both demonstrate a good knowledge and understanding of residents’ needs. The deputy manager has been nominated for the “carer of the year” award; the comments from relatives include: “totally dedicated” “exceptionally caring nature” “makes time for the family” “the love and care was always there, no matter what time of day we visit The home has a quality auditing system in place and surveys are distributed annually to the residents, their relatives and professionals who use the service. The results are positive from the last survey completed in July 2008. The manager also holds weekly ‘surgeries’ with the families who wish to see her. The home does not manage residents finances, but do provide a facilities for residents to safely keep small amounts of money. The system is audited by external auditors for added security. We looked at the accident records for the home, and these were found to be fully completed. We saw records to show that the home has regular schedule for maintenance checks. The fire records were up to date and detailed.. Throughout the home we observed good health and safety practise, for example fire doors were kept closed, there were no trip hazards, the flooring was in good condition and the lighting levels were adequate. The Annual Quality Assurance Assessment completed by the manager provided an accurate reflection of the home and their plans for improvements over the next 12 months. Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 24 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 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bowood Mews DS0000018485.V371866.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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.V371866.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V371866.R01.S.doc Version 5.2 Page 27 - 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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