Inspection on 23/08/05 for Crowmoor House

This inspection was carried out on 23rd August 2005.

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

Crowmoor House 18/09/07

Crowmoor House 20/04/06

Crowmoor House 23/01/06

Crowmoor House 05/01/05

Crowmoor House 30/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Crowmoor House Frith Close Monkmoor Shrewsbury SY2 5XW Lead Inspector Karen Powell Unannounced 23 August 2005 10.00 rd 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. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Crowmoor House Address Frith Close Monkmoor Shrewsbury SY2 5XW 01743 235835 01743 340804 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) Shropshire County Council Mrs Catherine Wallington Care Home 58 Category(ies) of 58 Old Age registration, with number of places Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 6th July 2005 - Ian Henderson Brief Description of the Service: Crowmoor House is a larger care home owned by Shropshire County Council and situated in the Monkmoor area of Shrewsbury. Made up of six individual units the home offers long-term accommodation, respite care and a rehabilitation service, which is run in partnership with the local health authority.The home is run by Cate Wallington for social services and she is assisted in this by her staff team. The building is purpose built to a design style that was popular some decades ago and has the advantage of being all on one floor. Date of last inspection Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted 4hrs. The inspection included discussion with the manager, service users and staff. Observation of daily routines, examination of service user records and a home tour took place as part of the inspection. The last inspection was carried out by the Commission for Social Care pharmacy inspector. The reason for the inspection was to ascertain what progress the home had made in meeting the requirements generated from the previous Pharmacy Inspection on the 3rd June 2005. It was judged that the medicine management within the home had improved since the last inspection but further systems still needed to be installed to ensure that all the residents’ medication needs were fully met. At this inspection a re visit to those requirements made at the pharmacy inspection on3rd June and 6th July 2005 was carried out. In addition to this several other core standards were assessed during the inspection. What the service does well: What has improved since the last inspection? Whilst minor pieces of work are required to fully meet the pharmacy inspection requirements from the 3rd June and 6th July visit it is evident that the home have made every effort to comply with the requirements made and work is almost completed. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 6 All toilets and bathrooms have been refurbished and look much better making them more pleasant areas for service users to use. All corridors have been re decorated and make the environment look welcoming and well maintained. Re design of unit four has created more lounge space and service users who occupy the area were very pleased with the end result. 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. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.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 Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.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) 3 Service users are assessed by an appropriately qualified person before moving into the home. EVIDENCE: A file of a new service user was examined and was seen to contain assessment documentation relating to the service user needs. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.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 & 10 Each service user has a plan of care setting out their needs and how these should be met. Service user health needs are fully met, health and social care professionals are involved in specialist needs of individuals where required. The medicine management within the home has improved since the last inspection. The home’s policies and procedures for the safe handling of medication are in the final stages of revision. Service users, dignity and right to privacy is acknowledged and promoted within the home. EVIDENCE: The care plans of two service users were examined. One was of a service user on respite and the other of a service user who had lived at the home for sometime. Both care plans were well written. However the care plan of the service user living at the home for sometime had not been reviewed since 1st February ’05. The home must show evidence that care plans are reviewed monthly. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 10 Evidence in individual care plans recorded well involvement of health care professionals where appropriate. Medicine management has vastly improved since the last inspection, minor pieces of work to fully implement the requirements made are required. These include finalising the new policy and procedures document for the safe handling of medicines. The installation of a storage cage for the safe storage of oxygen cylinders had been installed on the day of the inspection, the home is awaiting a lock for the cage to keep it fully secure at all times. A competency-monitoring programme to ensure the correct administration of medication has been developed but not yet implemented in practice. This will be reviewed at the next inspection. All other requirements in relation to medicine management have been fully met. Service users spoken to told the inspector that they felt their privacy and dignity was maintained by staff at all times. Examples given were during personal care delivery and entering service users private individual space. Observations of care staff on the day of the inspection showed care staff treating service users in a respectful manner. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.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) 12, 13 & 15 Service users are supported to undertake activities of their own choice. Visitors are welcomed into the home and service users are able to maintain contact with their family and friends. Service users are offered a varied, well balanced diet, which takes into account individual likes and dislikes along with seasonal changes. EVIDENCE: Service users told the inspector that a holiday organised in June to Bodelwyddan Castle was thoroughly enjoyed by those who took part. Pictures in the hallway showed the weeks activities undertaken. A variety of activities take place on a regular basis, a list of which is displayed for service users in the individual units. Service users told the inspector that a B-B-Q was arranged for the next day. Some service users were out on a trip for the afternoon and returned during the inspection. They enjoyed a trip to Carding Mill valley and Bishops castle. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 12 The previous week service users had visited Church Stretton. Visitors were seen to come and go during the inspection visiting individuals in the privacy of their own rooms. Service users spoken to were very complimentary about the quality of food. The home has a menu in place, which is seasonal. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 13 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 Appropriate procedures are in place to deal with complaints. EVIDENCE: Records showed there had been two complaints since the last inspection. These were seen to be recorded and detailed the action taken and outcome of the complaint. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 14 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, 20, 21 24 & 26 The environment of the home has improved since the last inspection, including redecoration of corridors and refurbishment of toilets and bathrooms. The on going programme of removing the remaining vanity units from bedrooms is included in the homes development plan. The standard of cleanliness was seen to be satisfactory. EVIDENCE: It was observed during the home tour that redecoration of corridors, re design of unit four and refurbishment of toilets and bathrooms has now been completed. Service users were very pleased with the outcome. The ongoing programme of removing the vanity units from bedrooms is included in the homes development plan. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 15 Installation of towel rails for service user convenience to the bathrooms should be considered to finish the refurbishment. The provision of liquid soap and paper towels to address management of the control of infection is required in all communal bathrooms and toilets. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 16 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 The home achieves minimum care staffing levels but on occasions falls short of having sufficient numbers of support staff in the home. EVIDENCE: Rotas seen and observation of staffing levels on the day of the inspection indicated that the home meets minimum staffing levels in relation to care staff. However discussion with staff and the person in charge indicated that there have been shortages mainly through illness of support workers placing pressure on care staff to fulfil housekeeping duties in addition to care duties. Whilst service users have not been placed at risk at anytime it was apparent that this situation is difficult for care staff to manage in the longer term. Discussion with the person in charge regarding the situation stated that where possible, on busier units managers and senior staff will attempt to provide cover by deploying existing staff to cover for support worker absence. This however is not always possible. Examination of the rota confirmed this. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 17 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 & 35 Service users are consulted with regard to their views about the service. Service users finances are handled appropriately in accordance with policies and procedures. EVIDENCE: Whilst service users could not recall any questionnaires being issued to them with regard to their views about the service, they shared with the inspector that the manager regularly consults with them regarding their views. It could not be confirmed by the person in charge, who was new in post when the last survey was undertaken. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 18 It was confirmed by the manager that regulation 26 visits are carried out by the responsible individual, however reports have not been forwarded to the commission since 18.3.05. Monies held at the home on behalf of service users are handled in line with the homes policy of handling service user money. A sample was checked and found to be satisfactory at the inspection visit. Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 19 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 x x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 2 x 3 x x x Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 20 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. 2. Standard 7 9 Regulation 15(2)(b) 13(2) Requirement Care plans nust be reviewed monthly New detailed procedures for the preparation, administration and recording of the Controlled Drugs must be formulated. It must be ensured that the designated staff must adhere to the written procedure and an audit, by the Manager, of the Controlled Drugs must be carried out on a weekly basis. A copy of the new procedure must be sent to the CSCI Pharmacist for reference. The policy and procedures document for the safe handling of medicines within the care home must be amended and updated to include the comments made by the Pharmacist Inspector. All stored oxygen must be securely chained against the wall. The home must remove the remaining vanity units from bedrooms maximising space for individuals. Liquid soap and paper towels must be installed in all communal toilets and Timescale for action Immediate 29.09.05 3. 9 13(2) 29.09.05 4. 5. 9 24 13(2) 12 29.09.05 24.01.06 6. 26 13(3) 24.11.05 Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 21 bathrooms. 7. 27 18(1)9a) The home must ensure that there are sufficient numbers of support staff given the size of the home, the statement of purpose and the number and needs of the service users Copies of regulation 26 visits must be forwarded to the Commission for Social Care Inspection Immediate 8. 33 26(5)9a) 29.09.05 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. Refer to Standard Good Practice Recommendations Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE 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 Crowmoor House E56 E01 S32792 Crowmoor House UAI V212736 230805 Stage 4.doc Version 1.40 Page 23 - 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!