Inspection on 31/01/06 for Bowood Mews

This inspection was carried out on 31st January 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 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 17/09/08

Bowood Mews 13/11/07

Bowood Mews 14/07/06

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 Y South Unannounced Inspection 31st January 2006 2pm 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.V279905.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 Mews DS0000018485.V279905.R01.S.doc Version 5.1 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 59270 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.V279905.R01.S.doc Version 5.1 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. 10th July 2005 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 and within easy reach of public transport systems and shops. It is a purpose built secure home on two floors and all bedrooms are single ensuite. There is a lift to the first floor. Each floor has a communal lounge and dining area and is staffed separately. There is an enclosed garden. The home shares laundry and kitchen facilities with Bowood Court, a sister home in the same grounds. Both homes are owned and registered by the same provider; Southern Cross Healthcare Services Limited. The registered manager of Bowood Mews is Mrs Susan Dianne Parkinson. Bowood Mews DS0000018485.V279905.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 three and three quarter hours from 2pm until 5.45pm. 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 Parkinson. The inspector spoke to residents and staff and a range of records was assessed. Input from the residents was limited due to their mental health. What the service does well: What has improved since the last inspection? Since the last inspection the dining areas have been re-floored and furnished and corridors and communal areas have been redecorated and carpeted. All the tasks identified in the last inspection report have been achieved. An activities organiser has been appointed to provide interesting and stimulating activities for the residents. Bowood Mews DS0000018485.V279905.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 Mews DS0000018485.V279905.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 Mews DS0000018485.V279905.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): 1 EVIDENCE: These standards were not assessed during this inspection. A requirement was made in the previous report to update the information in the Statement of Purpose and the Service users Guide. These have now been done and copies have been supplied to the Commission for Social Care Inspection as is required. Bowood Mews DS0000018485.V279905.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): 8, 9. EVIDENCE: These standards were not assessed during this inspection. Requirements made relating to risk assessments for residents had been met. The manager said that a senior member of staff, appropriately trained, was now always on duty and available to administer medication. However there was some concern as the training matrix indicated that only a small number of staff were trained to undertake this duty. Bowood Mews DS0000018485.V279905.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): 12, 13, 14, 15. The new member of staff ensures that residents are going to be provided with a range of stimulating activities in which they can participate if they wish. Links are maintained with the community as far as possible and residents are able to make life choices within a risk management framework. EVIDENCE: A new activities organiser had just commenced her duties and was getting to know the residents and their interests and abilities. The manager said that a flexible programme would then be drawn up. Specialist training would also be obtained for this staff member. Visits were undertaken by members of different churches with varying success It was acknowledged that it was important that some understanding of the dementia condition was helpful to such visitors. A choice of meals was offered from a large print menu but it was generally considered that a simple choice offered at meal times was more successful despite the inevitable risk of increase in waste. Bowood Mews DS0000018485.V279905.R01.S.doc Version 5.1 Page 11 Visitors were warmly welcomed and supported. Privacy could be provided for visits if required. The home had placed an advertisement in the local press for volunteers and had received a good response. The applicants would be taken through the recruitment process. Residents were unable to manage their own medication. Therefore this was being undertaken for them by the home in an acceptable manner. Personal possessions were brought into the home. However relatives were warned that the nature of dementia could lead to losses. They were urged to name everything so that it could be returned to its rightful owner when found. Some residents liked to use their rooms during the day and others preferred company. Some bedroom doors were kept locked when the occupant did not wish to use the room. Ownership of bedroom door keys had not proved successful but staff were always available to enable residents to enter their rooms when they wished. Bowood Mews DS0000018485.V279905.R01.S.doc Version 5.1 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 the following standard(s): 16, 18. Residents were protected by the availability and use of protection procedures. EVIDENCE: Issues relating to a staffing matter had been brought to the attention of the Commission for Social Care Inspection and will be addressed separately. Policies and procedures regarding whistle blowing and protection were available and detailed. Training was being provided for staff. Bowood Mews DS0000018485.V279905.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): 19, 26. The residents are able to live in a pleasant environment and the staff have access to equipment to reduce the risks of cross infection. EVIDENCE: These standards were not assessed during this inspection. Following the last inspection requirements were made that the carpets in the dining rooms and corridors must be replaced and gloves must be made available in all toilet areas. These requirements had been met. Bowood Mews DS0000018485.V279905.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): 27, 28, 29, The recruitment process was implemented to ensure appropriate people were employed in the home. The well being of staff was considered in their work practice. EVIDENCE: Following the last inspection requirements were made that a senior member of staff must be on duty at all times during the night, staff must not work excessive hours and consideration should be given to the introduction of a member of staff starting work at 7.00 am to ensure that residents were supervised appropriately. The manager confirmed that these first two events had been isolated incidents and no longer occurred. A member of staff was now rostered to commence duty at 7am each day. However there were some difficulties as not all staff had access to transport. A solution was being sought. The records of two staff were assessed and the required checks had been made when they were recruited. Support was given with induction through as much supervision as the individual needed. Bowood Mews DS0000018485.V279905.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): 31, 35, 37, 38. The management of the home ensures that the home is well run and the standards of care provision are acceptable and meet the needs of the residents. Records are well maintained to provide information and guidance. Health and safety for those in the house needs to be improved by increasing medication, first aid training and fire safety training. Regular servicing and monitoring of equipment reduces environmental risk. EVIDENCE: The registered manager has worked in the home for eight years and been the registered manager for the last three. Bowood Mews DS0000018485.V279905.R01.S.doc Version 5.1 Page 16 The post of deputy was currently vacant and recruitment was in progress. A senior carer was ‘acting up’ until an appointment was made.’ The residents’ personal monies were observed to be well managed with due regard to security and record keeping. The training matrix indicated that health and safety training was being provided. However only four staff were trained to administer medication and four staff were first aid trained. There should be one person trained to administer medication, and a qualified first aider (some one who has successfully qualified on the four day first aid at work course) on duty at all times. The small number of staff trained in these areas makes the demands on them very heavy. The manager confirmed that the shortage was being addressed and it was suggested that training priority was given to senior staff and night staff. 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 was discussed. Maintenance and monitoring of services and equipment was being undertaken. Risk assessments for the environment were not available. Bowood Mews DS0000018485.V279905.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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X 3 2 Bowood Mews DS0000018485.V279905.R01.S.doc Version 5.1 Page 18 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. 1 Standard OP38 Regulation 13 Requirement A first aider (four day First Aid at Work Qualification) must be on duty at all times. 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. Timescale for action 01/09/06 2 OP38 23 01/04/06 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.V279905.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 Mews DS0000018485.V279905.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. 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!