Inspection on 09/08/06 for Lower Bowshaw View Nursing Home

This inspection was carried out on 9th August 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 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 19/12/05

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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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 Mr Rob Curr Unannounced Inspection 9th August 2006 08:30 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.V299513.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 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 none 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.V299513.R01.S.doc Version 5.2 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. 19th December 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. Current fees range from £410 - £475. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. The site visit was from 8.30 am until 4.00 pm. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, rotas, staff training and recruitment and fire records. A number of care staff and nurses were spoken to about their skills and experiences of working at the home. Discussions took place with the registered manager and a director of the company. A number of residents were interviewed along with four relatives. The inspector would like to thank the manager and her staff team for their support during the inspection process. What the service does well: What has improved since the last inspection? Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 6 A comprehensive care plan format had been introduced. This format clearly indicated what action was required by staff to meet the resident’s needs. Staff had completed the ‘Medication Management Course’ and 50 of the care staff have achieved NVQ level 2 or higher in ‘Care’. 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.V299513.R01.S.doc Version 5.2 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.V299513.R01.S.doc Version 5.2 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, 2 and 3. Standard 6 was not applicable. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. Residents’ needs were assessed prior to admission. Residents and their relatives were fully involved in the assessment and admission process, so this ensured that the home was able to meet their needs. The manager did not offer places to any individual whose needs they could not meet. The staff-training plan was on target. EVIDENCE: Copies of full need assessments were in the residents files. All the relevant information from the assessments had been built into the care plan. Two relatives said that they had been invited to view the home and attend a variety of meetings prior to their relative moving into the home. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 9 Staff training records indicated that they had undertaken relevant training required to assist them in caring for the people that reside at Lower Bowshaw View. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 10 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 and 10. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. Each resident had a plan of care, to inform staff of the actions required to meet assessed need. Records indicated that residents’ health care was monitored, to maintain health. The recording and administration of medication was well managed, to promote residents safety, although there some minor errors relating to recording in the medication sheets. Interactions observed between residents and staff evidenced that resident’s privacy and dignity was respected. Written policies and procedures were in place regarding dying and death, to ensure residents and their relatives were supported sensitively. EVIDENCE: A number of care plans were examined. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 11 Some sections of the care plans seen were comprehensive and contained detail of the staff action required to ensure needs were met, for example, methods of communication. Care plans contained information on contacts with health care professionals, such as general practitioners and specialist nurses. There were a number of residents being care for in their bedrooms. On meeting these residents it was observed that they all had the appropriate support in terms of general health care and personal hygiene. The plans contained records of health assessments, such as moving and handling and skin integrity. Nutritional assessments were undertaken. Residents and visitors said that health care needs were met. Qualified staff administered medication. Part of a medication administration round was observed; medication appeared to be administered correctly and safely. Medication was stored securely. Not all medication administration records were fully completed. There were some minor issues around the medication recording system, however, the deputy manager, who undertakes a thorough audit of the medication system identified these errors. Once identified the problem is rectified by the person responsible. The audit records were comprehensive and up-to-date. Staff were observed to respect service users privacy by closing bathroom and bedroom doors. They were also seen to knock on doors before entering. Residents were able to choose whether to spend time in their rooms, or in communal areas. Peoples preferred form of address was respected. One resident said that he had complex needs and that new members of the staff team were never allowed to support him until they had the appropriate induction. He felt that this upheld his privacy and dignity. Staff promptly responded to residents that became anxious in a kindly, reassuring and patient manner. One relative said that staff were ‘always patient with my sister’. A policy and procedure were in place regarding dying and death. Relatives spoken with confirmed that they were kept informed of their loved ones health. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. Activities were provided to residents by members of staff and invited entertainers, to improve choice and quality of life. The routines at the home were flexible and service users were in the main able to choose how to spend their time, in line with health and safety and assessed risk, to maintain and improve the quality of life. However some residents could not always decide when to rise from bed for breakfast. An open visiting policy was in operation, in order to develop and maintain good relationships with resident’s representatives. Contact with relatives and friends were supported. The homes menu was varied, and special diets were catered for, to meet residents’ needs and maintain health. The catering team are very committed to providing a choice of menu, supporting any resident that has individual likes and dislikes. EVIDENCE: Three residents said that the ‘entertainment was good’, ‘we always know what’s happening’ and ‘yesterday we did a really good quiz’. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 13 Residents were seen to walk freely around the home. A visitor spoken with said ‘I am always made to feel welcome, and have no concerns at all about the care of my sister, I am very happy with the care provided’. Staff supported residents choices, and were overheard to offer individuals choice of breakfast. Three residents said that ‘sometimes we have to wait a long time to get up in the mornings’. ‘There are not enough staff sometimes’, ‘so we have to wait until they are free’. The homes menu was varied and choices were offered. One resident spoken with said the food was ‘very good’. This person had special dietary needs and said that other professionals come to advice the staff team of his requirements. Staff sat with the residents that required assistance with eating, and this support was given patiently and respectfully. However, whilst one member of staff was assisting a person with their meal the other member of staff was supporting the remaining residents. The inspector noted that a number of people required assistance with taking a meal. The cook and her team were clearly aware of individual residents special dietary requirements. There were plentiful stocks of food, which staff had access to, to provide snacks and drinks during the evening and night, if required. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened and responded to. An adult protection procedure was in place. Staff were fully aware of these procedures, to ensure residents safety was promoted. EVIDENCE: The complaints procedure was on display in a communal area of the home. This procedure informed residents and their representatives of the providers approach to complaints. A record of complaints was kept. One complaint had been received sine the last inspection – this had been handled well and the outcome was recorded. The staff spoken with were clear about the procedures to undertake in regard to adult protection and about the homes complaints procedure. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. The home was clean and generally well maintained, to provide a pleasant environment for residents. Controls of infection procedures were in place, to promote resident’s health and safety. EVIDENCE: A tour of the building identified that some areas of the home were in need of minor repair. The manager had highlighted these to the inspector and the repairs had been identified in the maintenance book. Some homely touches were provided to create a comfortable environment for the residents. A handy person was employed to help maintain the Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 16 environment. A rolling programme of redecoration and replacement was in place. Control of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area was poor. This judgement has been made using available evidence, including a visit to the home. Sufficient staff were not provided to meet the needs of residents. The required levels of NVQ trained staff had been achieved. The recruitment policies and procedures were not followed consistently. These practices do not ensure that staff are suitable for the post. A comprehensive range of training was provided to all staff, to improve their skills and enable them to support residents effectively. EVIDENCE: The rota evidenced that appropriate levels of staff were being maintained. However, it was noted by the inspector that the high level of dependency was impacting of the choice offered to residents. Three residents spoken with said that there were not enough staff provided. Two visitors spoken with said they were unhappy with the levels of staff. This was discussed at length with the manager, who agreed that there had been a recent change in the dependency levels of some residents. The manager stated that she was to meet with the director immediately to discuss and rectify this. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 18 The home had recruitment systems in place to protect residents, however, the following issues were noted: • • • • Application forms had not been fully completed Full employment histories had not been provided Not all references were from previous employers Three (3) members of staff did not have a criminal record bureau disclosure. It was agreed with the manager, that none of these staff would work unsupervised until a full CRB disclosure had been received and that they would apply for a ‘POVA first’ check immediately. The manager made a commitment to take immediate action. Ten care staff had achieved NVQ Level 2 or above in care. A number of care staff had also commenced the training. This clearly met the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. Induction and ongoing training were provided to staff. The deputy manager had worked hard to maintain training records and ensure appropriate training was available to staff. A training matrix and individual training records were maintained, to assist in monitoring the training provided. This matrix highlighted a small number of staff that had not yet received training in adult protection. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 19 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, 35, 36, 37 and 38. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. There was a positive style of management in the home. This clearly benefits the residents and their relatives and representatives. There was a quality assurance system in place, which gave residents and visitors an opportunity to express their views and suggest ways in which the service may be improved. Staff supervision systems were in place to ensure best practice was maintained. All records were securely stored. Health and safety hazards were identified; this did not ensure residents were safe. All staff had undertaken fire training. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 20 EVIDENCE: Staff said that the manager was approachable, supportive. One adaptation nurse was very grateful for the education and support she had received from the management. The manager had an annual plan that identified and prioritised areas for improvement, to enhance the service provided. The ‘quality assurance questionnaire report’ was able to inform relatives and other interested parties, the current views of the service. Care staff and nurses said that the frequency of their supervision sessions had lessened, although they acknowledged that this could be due to staff sickness and annual leave. Fire records were maintained of fire alarm tests. The fire drill records indicated that staff (including night staff) had undertaken a fire drill practice within the last year. There was inappropriate storage under two separate stairwells that were on a fire exit route. Portable oxygen therapy units are in use. The inspector noted that the cables relating to one of the units was creating a tripping hazard. The nurse-in-charge actioned this immediately. Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 21 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 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 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 2 Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 22 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 OP14 Regulation 12 Residents must have a choice in rising and retiring times. 2 OP14 OP15 12,18 Extra staff must be made available during mealtimes to ensure resident’s needs are fully met. 13 Sch 2(7) All staff that have not had adult protection training must do so. The identified members of staff that had no CRB, POVA first, or references must not work unsupervised until all the required checks have been completed. Under no circumstances must staff be recruited prior to an appropriate CRB disclosure being received. All recruitment procedures must be adhered to. All staff must receive supervision at the required intervals. Staff must be made aware of DS0000021795.V299513.R01.S.doc Requirement Timescale for action 09/08/06 09/08/06 3 4 OP18 OP29 06/10/06 09/08/06 5 OP29 Sch 2 09/08/06 6 7 8 OP29 OP36 OP38 Sch 2 18 13 09/08/06 06/10/06 15/09/06 Page 23 Lower Bowshaw View Nursing Home Version 5.2 potential tripping hazards resulting from trailing cables. 9 OP38 13 Fire exits must be kept clear at all times. 10 OP38 13 All electrical cleaning equipment must be safe and fit for its purpose. 15/09/06 09/08/06 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 Lower Bowshaw View Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office 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 Nursing Home DS0000021795.V299513.R01.S.doc Version 5.2 Page 25 - 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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