Inspection on 19/12/05 for Lower Bowshaw View Nursing Home

This inspection was carried out on 19th December 2005.

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

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

Other inspections for this house

Lower Bowshaw View Nursing Home 29/07/08

Lower Bowshaw View Nursing Home 11/09/07

Lower Bowshaw View Nursing Home 09/08/06

Lower Bowshaw View Nursing Home 03/05/05

Lower Bowshaw View Nursing Home 13/01/05

Lower Bowshaw View Nursing Home 22/07/04

Lower Bowshaw View Nursing Home 09/03/04

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Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lower Bowshaw View Nursing Home Low Edges Crescent Sheffield South Yorkshire S8 7LN Lead Inspector Unannounced Inspection 19th December 2005 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 Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 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. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lower Bowshaw View Nursing Home Address Low Edges Crescent Sheffield South Yorkshire S8 7LN 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) 0114 237 2717 0114 237 5743 Total West Limited Miss Jennifer Louise Gordon Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One individual who is identified on the application for variation for registration dated 14/05/04 at 4.1 may be accommodated. The minimum age of 55 years must have been attainted by the individual before he can reside at the home. 3rd May 2005 Date of last inspection Brief Description of the Service: Lower Bowshaw View is a purpose built nursing home which provides single bedroom en-suite accommodation for 40 older people. It is located in a residential area of Sheffield with good access to public services and amenities. Accommodation is on two floors; the first floor is accessed by a lift. The home has six lounges and dining rooms, a garden area, and car parking facilities. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between the hours of 9.00 am and 3:30 pm. Jenny Gordon was present during the inspection process and has been managing the service for a number of years. The inspector was escorted on a partial tour of the home. A variety of policies, procedures, and records were checked. The residents were very helpful during the inspection process, offering ample opportunity to talk about what life was like at the home. In all – 6 residents, 5 staff members, and 3 visiting relatives were spoken to. What the service does well: What has improved since the last inspection? A comprehensive care plan format has been introduced. This format clearly indicates what action is required by staff to meet the residents needs. The training matrix was up to date and clearly highlighted training undertaken by the staff team. The registered provider is undertaking monthly audits of the service and proving the CSCI with an account of this. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 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. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 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 Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 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, 3 and 5. Standard 6 was not applicable. Resident’s records included a detailed assessment of their needs. EVIDENCE: Three care plans included assessments carried out by staff at the home, and information from the placing authority. Two relatives stated that they had been asked for information prior to their admission. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 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): 7,8,9,10 and 11. Health care was monitored and care plans were reviewed on a monthly basis. A range of health care professionals visited the home to assist in meeting the needs of the residents. Medication was in the main managed safely, however there were some difficulties around the ordering of medication. Service users privacy and dignity was respected. Service users wishes regarding dying and death required recording, to ensure these were carried out. EVIDENCE: A new care plan format had been introduced. This was gradually being actioned. The care plans seen by the inspector were the in the new format. Three care plans set out in detail the residents needs and the action to be taken by the qualified and care staff of the home to ensure all these could be met. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 10 Residents could see their GP in private so that their privacy and dignity was respected. There was a medication policy and the medication and records were stored securely. On the day of the inspection, some of the medication that had been ordered by the home had not arrived. There appeared to be some confusion with regard to the ordering system at the GP surgery and contracting pharmacist. There were a number of MAR sheets that contain information about medication that had been discontinued some time ago. Staff closed doors before assisting residents with personal care. Staff knocked on residents does and waited before being invited in. Residents and relatives said that said that staff were ‘polite’ and ‘helpful’. Although a number of residents have communication difficulties, some residents said that they were happy in the home and said, “the staff are nice and kind” and ”I’m happy here”. Relatives said they were “very satisfied” with the care delivered by staff. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14 and 15. Residents and relatives were happy with the activities and outings. Mealtimes were well managed with dining areas to accommodate all service users. The home had clear visiting policies and procedures to ensure that residents could maintain contact with their family and friends. Residents are encouraged to bring in personal items of furniture and ornaments to help them settle into their own bedroom. The cook had reviewed the menu, to improve choice and reflect service users preferences. EVIDENCE: A number of activities were organised. Residents said that they had enjoyed a carol service recently and had also enjoyed a Christmas dinner at a restaurant. The manager stated that when the weather improved there would be outings. This would enhance their lifestyle experience. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 12 Visitors to the home praised the staff. Visitors confirmed that they liked to visit their relative in the main lounge, while others preferred to see their relative in their own bedroom. Residents receive support from other people visiting the home, e.g. hairdresser, optician, chiropodist, and representatives from the local church, maintaining contact with the local community. A partial tour of the building provided evidence that service users were able to personalise their bedrooms, many had brought in small items of furniture and pictures of their family. The mealtime was well organised and the inspector was able to observe residents being assisted with their meal where required. Staff were unhurried and there were sufficient numbers to ensure those residents who were being cared for in their bedroom were taken a meal that looked appetising. The cook had work hard to develop the menus. This had resulted in a clear choice at mealtimes. The cook kept a clear record of the food that had been offered and served. The cook had applied to train for a food hygiene certificate at an ‘Intermediate’ level. There were no outstanding issues required by the Health Protection Service. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18. Relatives and staff were aware of how to make a complaint and were confident that they would be listened to. An adult protection procedure was in place to ensure service users safety was promoted. The majority of staff had undertaken formal training in adult protection. EVIDENCE: The complaints procedure was on display in the foyer, which contained relevant information and provided the reader with details of who to contact outside the home, to ensure complaints were taken seriously. The home kept a record of complaints. Staff spoken to were aware of the local Adult Protection Procedures. The residents, relatives, and staff all stated that they had confidence in the homes manager. They said that she would listen and respond to any concerns they raised. One relative said that he was invited to relatives meetings to discuss issues. All the residents spoken to said they felt safe at the home. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 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 the following standard(s): 19,20,21,22,23,24,25 and 26. The home was clean and generally well maintained. Communal areas were homely, and were well decorated. Sufficient bathing facilities were provided. The bedrooms seen were personalised by residents and their relatives. The home was free of any offensive odours. Systems for the control of infection were in place. A call system was available in all rooms used by the residents so that they could summon assistance at all times. EVIDENCE: The inspector carried out at tour of the home. All of the residents spoken with were happy with their bedrooms and the furniture provided. The home was well decorated and well maintained, to provide a comfortable environment for the residents. It was evident from care plans that a number of people needed support with continence difficulties. The ancillary staff that worked in the laundry had a clear understanding of health and safety issues including infection control. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 15 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. Sufficient staff were provided to meet the needs of the residents. The recommendation that 50 of the care staff team are qualified to National Vocational Qualifications (NVQ) level 2 in care had not yet been achieved. The manager and her deputy could identify the training needs of the staff group. This assists in maintaining the well being of the residents. Recruitment policies are followed ensuring the safety and protection of the residents. EVIDENCE: Staff rotas examined showed sufficient staff to meet the needs of service users. Staff had adequate skills to meet the needs of service users, although they do not quite meet the recommendation of 50 NVQ qualified care staff. A number of staff continue to work towards the award. Some care staff have achieved an NVQ qualification at level 3 and others were also registered to train for this award. The ancillary staff were involved in a variety of training events including NVQ in cleaning and support services. A number of staff recruitment files were examined and found to be complete. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31,32,33,36,37 and 38. The registered manager has the required skills and competencies to ensure the safety and protection of the residents . Staff are provided with formal supervision. Health and Safety policies are in place for the health, safety, and welfare of those individuals who work and live at the home. EVIDENCE: The registered manager has been in post for a number of years. Staff supervision has not taken place at the recommended frequency, although this has not been detrimental to the care of service users. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 17 Servicing of essential equipment takes place within the recommended timescale and records examined provided evidence of this. The home had a comprehensive auditing system for the accidents that had occurred. However – this auditing had not been kept up to date. This could compromise the safety of the residents. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 18 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 2 2 Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation 13 Requirement The manager must improve communication between the home, GP service, and pharmacists. The MAR sheets must be reviewed to remove all medication that has been discontinued. All staff that have not had adult protection training must do so. All staff must receive supervision at the required intervals. The auditing system must be brought up to date and continues. Timescale for action 15/02/06 2 OP9 13 15/02/06 3 4 5 OP18 OP36 OP38OP37 13 18 18 15/02/06 15/02/06 15/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The replacing of the care plans with the revised format should continue. Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Lower Bowshaw View Nursing Home DS0000021795.V267188.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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