Inspection on 03/05/05 for Lower Bowshaw View Nursing Home

This inspection was carried out on 3rd May 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 19/12/05

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

CARE HOMES FOR OLDER PEOPLE Lower Bowshaw View Low Edges Crescent Sheffield South Yorkshire S8 7LN Lead Inspector Claire McAuley Unannounced 3rd May 2005 9:00 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. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lower Bowshaw View Address Low Edges Crescent Sheffield S8 7LN 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) 0114 237 27 17 0114 237 57 43 None Total West Limited Miss Jennifer Gordon Care Home with nursing 40 Category(ies) of OP Old Age (40) registration, with number of places Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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. Date of last inspection 12 January 2005 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 J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 8.5 hours from 9.00 to 17.30. Previous requirements were checked as well as the majority of key standards. A tour of the building took place and eight residents expressed their views on aspects of living at the home. Three relatives and three members of staff also expressed their views on the care provided at the home. A number of records were checked. What the service does well: What has improved since the last inspection? What they could do better: In order to maintain the safety and proper care of residents, care plans required improvement, including more detailed risk assessments, review of sanctions, resident and relative reviews, and detailed recording on pressure care. Recording of accidents, and professional visits made by the tissue viability nurse was inadequate. A notifiable incident had not been notified to the CSCI. Staff required further training on observing resident’s privacy and dignity. There were errors in medication administration and storage. The home was short staffed at times. Agency staff were used on a large number of shifts, creating a lack of continuity of care for residents and low morale in the staff team. Supervision of staff had not been completed at the required level. Sufficient permanent staff must be recruited and properly supervised to meet the needs of all residents. In order to maintain the comfort of residents, some areas of the home required re-decoration, and cleaning, and the outside garden area required maintenance. The residents were unable to access the smoking room as it was locked. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 6 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 J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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 Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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) 1 3 The statement of purpose and service users guide contained the majority of required information and was available for residents. Full needs assessments were undertaken. EVIDENCE: The statement of purpose and service users guide contained the majority of required information. Copies of these were seen in resident’s rooms and in the entrance hall. Full needs assessments were undertaken prior to resident’s admission to the home in order to identify their needs. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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 Care plans required further improvements to identify and meet resident’s needs. Inadequacy of recording on pressure care meant that resident’s health needs were not fully met. There were a number of errors in medication administration and storage that could put residents at risk. Staff were aware of how to maintain resident’s privacy and dignity but this was not always maintained in practice. EVIDENCE: Resident’s plans of care were in place. Some improvements were needed to meet their needs. Some entries were difficult to read. Risk assessments did not contain sufficient information or action to be taken to reduce risk or to meet resident’s needs. Sanctions, such as the use of cot sides had not been reviewed and there was no evidence of reviews involving residents or their relatives taking place. Pressure care treatment was not recorded in sufficient detail and there were days when no recording had taken place. Professional visits from the tissue viability nurse had not been recorded. This could put residents health at risk. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 10 In order to meet their health needs, residents received visits from their G.Ps, dentists, opticians and other healthcare professionals. Nutritional screening was undertaken for all service users, with food and fluid intake records in place. Medication records were checked, and there were a number of omissions in recording the administration of medication. A resident’s discontinued medication had not been returned to the Pharmacist. Creams were also left on the handrail in a corridor, and the medication trolley was left unattended for short time. These errors potentially put service users at risk. The medication cupboard and controlled drugs cabinet were not sufficiently large to contain the number of medications required by all the residents. This meant that medicines were crammed together and difficult to identify. Some residents said that staff were pleasant, competent and kind, and that their privacy and dignity was maintained. Staff members confirmed the measures they took to ensure this. A resident said that she/he had been handled roughly and shouted at by a member of staff. A staff member was seen to enter a resident’s room and a bathroom without knocking. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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 Residents chose how they spent their day. Not all residents were happy with the activities provided. Residents brought personal items into the home for their comfort. Visitors were welcomed. The food served was of good quality and there was a good choice. The practice of using plastic drinking mugs and beakers did not maintain resident’s choice or dignity. EVIDENCE: The home provided a range of activities which took place each afternoon. Activities included card and board games, bingo, and music. A religious service took place monthly. Entertainers visited the home. Large print books and newspapers were available. Residents could join in with activities as they wished. A number of residents spent time in their rooms and others were observed moving around the home and interacting with other residents and visitors. Some residents spoken to said there was not enough to do at the home. A resident requested a visit from a Church of England Minister. Personal items had been brought into the home by residents to personalise their rooms and make them feel at home. A number of relatives and friends were visiting the home. They said they were able to visit at any time, and were made welcome. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 12 Residents all said that the food was good and there was a wide range of food offered, including fresh vegetables and fruit. Residents said they were asked what they liked to eat. The lunchtime meal was appetising and attractively served and those who needed help were offered this in an appropriate way. The cook was aware of special diets and liquidised food was attractively served. Drinks were served regularly throughout the day. Plastic beakers were used for cold drinks, and plastic mugs, which were badly stained, were used to serve tea, and other hot drinks. This practice did not maintain resident’s dignity or choice. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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 18 The complaints and adult protection policies procedures, and staff training promoted the protection of residents. EVIDENCE: The home had a complaints procedure that residents could access. Residents and relatives said that they knew who to speak to if they had a complaint about their care. The home had received two complaints, which were in the process of investigation. The manager said that all complaints were responded to within 28 days. The home had a policy and procedure on adult protection. Staff members were trained in adult protection, and said they would report any potential abuse to the manager. Management were aware that any incidents of abuse must be reported to Social Services Adult Protection procedures. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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 26 The home was clean, safe and generally well maintained. The building complied with the requirements of the fire service and environmental health department. Appropriate facilities were provided. Outside areas of the home were accessible to residents, although some maintenance of the gardens was required. Some redecoration and cleaning within the home was necessary. Laundry facilities were appropriate and there were policies and procedures in place for the control of infection. EVIDENCE: All residents’ areas of the home were clean and generally well maintained. Furnishings and furniture were of a good standard. There was a maintenance and renewal programme in place. The garden area was accessible to residents, however, some maintenance was required as flowerbeds, and flagged and grassed areas were overgrown with weeds. The kitchen ceiling, cooker and dishwasher required cleaning. There was a leak under the kitchen sink, staining the floor. The dining room on the first floor required redecoration, and there was no light in one upstairs toilet. A number of doorframes and skirting boards were damaged by wheelchairs and trolleys. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 15 The building complied with the requirements of the fire service and environmental health department. The smoke room was locked, and could not be accessed by residents. Furniture in the conservatory was not available for residents to use. The home was clean and fresh smelling and provided a pleasant environment for residents. Laundry facilities were appropriate. The home had policies and procedures in place for the control of infection and staff had received training on this. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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 29 30 The home was short staffed at times, presenting a potential risk to residents. Agency staff had been used to cover a large number of shifts, and issues of staff continuity and morale had resulted. Recruitment procedures and policies met requirements, and the training programme was extensive. EVIDENCE: The home was short staffed at times. This could put service users at risk. The rotas checked for the month of April 2005 showed that there were a small number of shifts where the required levels of staff were not on duty. The manager said that there were some staff vacancies at the home, but some new staff had been recruited and were due to start when their CRB and POVA checks had been completed. The home had employed agency workers to cover a large number of shifts. The staff interviewed said this lowered morale at the home and made it hard to provide continuity of care. Recruitment files contained the full range of required information. A staff training and development programme was in place that met NTO workforce training targets. External trainers also provided training, which included Catheter Care, Pressure Care, Oral Hygiene and Palliative Care. Staff confirmed that they received regular training in order to meet resident’s needs. Training records were maintained for all staff employed at the home. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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 36 37 38 A quality assurance and monitoring system to measure the standard of the service provided was in the process of development. Monitoring visits had not been undertaken by the Responsible Individual to establish if the aims of the service were met. Supervision of staff had not been undertaken at the required level for all staff, therefore promotion of good practice was incomplete. For the safety of residents, staff had completed mandatory training, although fire training was due for renewal. The accident records were insufficiently detailed and did not promote the safety of residents. A notifiable incident had not been reported to the CSCI. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 18 EVIDENCE: The home was in the process of developing a quality assurance system, including monthly audits on care plans, the environment and management issues. Audits to ascertain the views of service users had been put in place, although information had not been collated and shared with service users and their relatives or representatives. Residents and relatives meetings were in place. Monitoring visits by the responsible individual in order to measure success in meeting the aims of the home had not taken place. The manager stated that the administrator had not yet been able to offer residents the opportunity to open individual bank accounts. Not all staff received supervision at the required level in order to maintain best practice. The manager said this was being addressed. The accident record showed that a number of accidents were not recorded in sufficient detail, including action taken following an accident, and the outcome. This could put residents at risk. One accident had not been recorded, and a notifiable incident form had not been sent to the CSCI. There was also no record of a resident having been admitted to hospital. Staff had received all the required mandatory training necessary for the maintenance of health and safety at the home, however, fire training was due for updating. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x 2 2 2 2 Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 20 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 7 Regulation 15 Requirement All plans of care must be legible and include comprehensive risk assessments,including action taken to reduce risk. The use of cot sides must be regularly reviewed and action taken recorded on plans of care. Regular reviews must take place with service users and relatives/representatives. These must be recorded. All residents pressure care treatment must be recorded in full detail on plans of care.There must be no gaps in dates of recording. All professional visits made, and action taken by the tissue viability nurse must be recorded. Recording of the administration of medication must be accurate and complete. Medication not in use must be returned to the Pharmacist. Creams and other medication must not be left in corridors. The drugs trolley must not be left unattended. The manager must undertake an enquiry into the allegations that a service user was roughly Timescale for action 1st August 2005 1st August 2005 1st August 2005 1st July 2005 2. 3. 7 7 15 15 4. 78 15 12 13 5. 6. 7. 8. 78 9 9 9 15 12 13 13 13 13 1st July 2005 3rd May 2005 3rd May 2005 3rd May 2005 1st June 2005 Page 21 9. 10 13 12 Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 10. 10 13 12 11. 12 16 12. 12 16 13. 15 12 14. 15. 19 19 23 23 16. 19 23 17. 18. 19. 20. 19 19 19 27 23 23 12 23 18 21. 33 26 handled and shouted at, and a report sent to the CSCI stating what action is to be taken. All staff must be appropriately trained in observing the privacy and dignity of residents. Staff members must always knock before entering bedrooms or bathrooms. The activities programme must be reviewed and further developed to include the needs of all residents. Arrangements must be made for a Minister of the Church of England to visit the resident who requested this. The use of plastic beakers and mugs must be discontinued unless there are medical reasons for residents to use specialised plastic equipment. Glasses and pottery mugs cups and saucers must be provided. The garden area of the home must be regularly maintained. The kitchen ceiling, cooker and dishwasher must be cleaned. The leak under the sink must be mended and the floor cleaned. the upstairs dining room must be redecorated, and damaged door frames and skirting boards redecorated. The light in the toilet must be replaced. The smoke room must be accessible to residents and not kept locked. Furniture in the conservatory must be made available for the use of residents There must be sufficient permanent staff employed at the home to meet the needs of residents at all times. The responsible individual must 1st July 2005 1st August 2005 1st July 2005 1st July 2005 1st July 2005 1st uly 2005 1st August 2005 1st June 2005 3rd May 2005 1st July 2005 1st August 2005 1st August Page 22 Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 22. 35 13 23. 24. 25. 36 37 38 7 18 37 Schedule 3 26. 38 13 18 carry out regulation 26 visits, (or their representative) on a monthly basis and a copy of these reports must be sent to the CSCI local office (Previous timescale of 1st March 2005 not met) All service users must be offered the opportunity to open an individual bank account.(Previous timescale of 30th April 2005 not met) Supervision of staff must take place at the required level of six times a year. All notifiable incidents must be notified to the CSCI. Accidents must be properly recorded, including action taken following an accident. All accidents must be recorded. Hospital admissions following accidents must be recorded on plans of care. Fire training for all staff must be updated. 2005 1st August 2005 1st August 2005 3rd May 2005 1st June 2005 1st June 2005 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. 2. 3. 4. Refer to Standard 1 1 9 28 Good Practice Recommendations The statement of purpose should contain all of the information required by the regulations. The service users guide should include service user views of the home. The medication cupboard and controlled drugs cabinet should be replaced with larger ones in order to contain the medication at the home in a tidy and accessible manner. 50 of staff should achieve NVQ level 2 or equivalent by 2005. Lower Bowshaw View J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Ground floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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 J55 21795 Lower Bowshaw 218754 03.05.05 UI Stage 4.doc Version 1.30 Page 24 - 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. 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