Inspection on 24/10/05 for Rowan House

This inspection was carried out on 24th October 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

Rowan House 19/12/07

Rowan House 04/07/07

Rowan House 26/09/06

Rowan House 18/07/05

Rowan House 30/11/04

Rowan House 17/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Rowan House 9 Darwin Road Shirley Southampton Hampshire SO15 5BS Lead Inspector Lorraine Parton Unannounced Inspection 24th October 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 Rowan House DS0000011873.V255342.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. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rowan House Address 9 Darwin Road Shirley Southampton Hampshire SO15 5BS 023 8022 5238 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) Mrs A Hurley Mr R Hurley Mrs A Hurley Care Home 16 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (16), Mental disorder, excluding learning of places disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (16), Old age, not falling within any other category (16) Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A total of 3 service users in the categories (DE) and (MD) may be admitted at any one time between 55-64 years of age. 18th July 2005 Date of last inspection Brief Description of the Service: Rowan House is a large three storey older style house situated in a quiet area of Southampton. Only the ground and first floor of the property accommodate service users and the top floor is the private residence of the owner. The home is registered for sixteen service users within the category of older persons, however, service users are also accommodated with varying levels of dementia. The home is owned by Mr and Mrs Hurley, Mrs Hurley is also the registered manager. The home provides seven double and two single room accommodation and none of the rooms have en suite facilities. The home has a kitchen, dining room and lounge on the ground floor and all of these rooms are accessable to service users. To the front of the property is a small garden and car park and to the rear is a large and pleasant garden that is used by many of the service users living in the home. The home is situated close to local shops and a short car journey away from the city of Southampton. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The second inspection of the inspection year took place over 5 hours and the purpose was to ensure compliance with previous legal requirements brought to the homes attention at the first inspection in July 2005 and to complete the inspection process for the year. The inspector audited 13 standards and reassessed 7 standards, in which the inspector had raised requirements at the last inspection. All key standards have now been assessed throughout the year. The inspection involved a walk around the home and an audit of some of the homes documentation. The inspector was assisted by the registered manager and one of the homes staff. Much of the inspection was spent talking to the service users who clearly displayed their involvement in the home. Service users spoken to advised the inspector that they enjoy living at the home and that the homes staff are ‘lovely’, ‘kind and caring’ and ‘fun’. Several service users commented on how homely the home is and that they feel happy because the staff respect them and their views. What the service does well: What has improved since the last inspection? The home has made an excellent attempt to ensure they are meeting and exceeding the requirements of the standards brought to their attention at the last inspection. All prospective service users are assessed by the home prior to being admitted into the home and these are documented. These assessments have been incorporated into the service user plans. All service user plans have been reviewed and developed since the last inspection. The home has amended the complaints procedure and brought it to the attention of all service users and their families. A copy of the homes information has been made available for all visitors to the home. The home has reviewed its staffing arrangements and ensures that adequate staff are on duty at busy times and when needed by the service users. The home has increased following consultation with service users the activities provided in the home. Every afternoon the home and the homes staff provide a wide range of activities that service users confirmed they enjoy. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 6 Service users confirmed that the home has involved them in the selection of menus and that the home provides a range of meals that are excellent. Service users confirmed that alternative menus are available and that meals provided are adequate. 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. Rowan House DS0000011873.V255342.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 Rowan House DS0000011873.V255342.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): 2,3,6 All service users have a contract of tenancy. All prospective service users are assessed prior to moving into the home to ensure identified needs can be met. The home does not offer accommodation to service users requiring intermediate care. EVIDENCE: The home has had one new admission since the last inspection and the inspector was able to assess the admission practices of the home. The home has reviewed these practices since the last inspection and had enhanced the initial assessment undertaken prior to agreeing to the admission of the service user. The home obtains information from the service user, care managers and families and includes personal care, relationships, events in the persons life, interests and hobbies and specific wishes of care and support required. The initial assessment was found to contain all relevant information and this forms a basic care plan for staff to follow. The home continually assesses the service user until the formation of a full care plan is completed. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 9 The new service user had been issued with a contract, which included terms and conditions of tenancy and a copy of the complaints procedure. A signed copy was found in the service user file. The home advised the inspector that they go through the contract, complaints procedure and service user guide with all service users or their families on admission. The home does not offer accommodation for service users requiring intermediate care or support. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 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, 9, Service users plans contain all relevant information. Medication practices are safe. EVIDENCE: The inspector audited three service users plans, which were found to contain all relevant information. The home had reviewed the care plans since the last inspection and had included more information in them. This included mental health and mobility areas, which had not been fully included at the last inspection. The home has undertaken service user risk assessments and these had been incorporated into the service user plans. The home has a medication policy and procedures, which include the requirements for administration, storage and recording of receipt and returned medication. The home operates a monitored dosage system that is provided by the local pharmacist who visits the home to monitor the medication on a regular basis. All staff undertake medication training prior to been able to administer medication and this training is provided by the local pharmacists. The home has information available for staff regarding the medication in the home. Rowan House DS0000011873.V255342.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, 15 Service users are supported in their chosen lifestyles and encouraged to make choices about their lives. Service users state the home provides a suitable range of activities. Service users confirmed that the home provides excellent food of their choice. EVIDENCE: Service users spoken to advised the inspector that the home has started to provide a wider range of activities and facilities since the last inspection. Service users confirmed that the homes staff ask them what they want and do their best to provide it. The home has purchased a video at the request of service users so that they can watch a variety of old movies. The home has employed the services of outside entertainment and the homes staff are undertaking a range of activities in the afternoons. This includes games, manicure sessions and singalongs. Service users who wish to participate in the home are able to do so, service users were seen to be participating in the home during the inspection, which included laying tables and tidying up. Service users spoken to confirmed that the home supports their choices in involvement in the home. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 12 The home has reviewed its menus since the last inspection and the provider ensures that service users are always offered a variety of choices. The provider advised the inspector that they have consulted with service users as to the menus and that the homes staff have been instructed as to the quality and quantity of the food being provided in the absence of the provider. Service users spoken to stated that the home provides good food and offers a choice of menu. Menus display a well balanced and nutritious variation, which, the service users stated are based on their likes and dislikes. Individual choices and needs in food are catered for and this includes likes, dietary needs and special requests. The inspector was present for the lunch time meal and it was noted to be well presented, nutritious and of a quantity that service users state meets their dietary needs. Meal times were noted to be relaxed and service users who were being supported were not rushed and their dignity was maintained. Rowan House DS0000011873.V255342.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, 17, 18 Service users are aware of how to make a complaint and to whom. Service users who wish to take part in the election process. The home has procedures and practices in place to protect where possible service users. EVIDENCE: The registered manager advised the inspector that all service users are given a copy of the homes complaints procedure on admission. A copy of the complaints procedure was on display on the notice board in the home. Service users confirmed that they were aware of the complaints procedure and that the homes staff had gone through it with them. Service users advised the inspector that they would speak to the homes manager or staff if they had any concerns and if unresolved would speak to their families or friends. The home has not received any complaints since the last inspection. A record of a complaint would be maintained if necessary. The registered manager advised the inspector that all service users are registered to vote and that service users wishing to take part in the election process would be supported. The home has a copy of Hampshire’s Adult Protection procedure and a whistle blowing policy. On speaking to staff they displayed their awareness of what constitutes abuse and the appropriate action to take if necessary. Not all staff Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 14 had received training in adult abuse awareness. A requirement for training has been made. The home has implemented suitable recruitment procedures to ensure service users are protected and three staff files were audited and found to contain all relevant information. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 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, 23, 26 The home is clean, safe and well maintained and provides a homely environment for service users. Service users who wish have personalised their bedrooms with their own belongings. EVIDENCE: The inspector undertook a walk around the home and identified no issues in the rooms that were entered. The home was found to be homely, clean and suitable for service users. All areas of the home are accessible to service users and the rear garden was found to be well maintained. At the time of the inspection service users were seen to be moving around the home and garden as they chose. All rooms seen were found to include service users own possessions and some rooms contained service users own furniture. The inspector noted that these rooms were homely and reflected service users own choice. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 16 The home has a maintenance programme and repairs are carried out as and when necessary. This provides a safe environment. The home has under taken risk assessments, however, the home needed to develop them to include the controls required for any identified risks. The home has fitted radiator covers to all radiators, thermostatic valves to hot water outlets and restrictors to windows on the first floor. All chemicals were found to be kept securely. The home has a range of policies and procedures for ensuring the safety of service users and this includes a suitable infection control policy. All certificates and insurances were found to be in place and up to date. The home has had a recent visit from environmental health where no issues were identified. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 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, 29, 30 The home had adequate staff on duty, who were found to be competent to do their jobs. The home has suitable recruitment procedures in place for the employment of new staff. Staff are receiving some training, however, this needs developing to ensure training is relevant to the service it provides. EVIDENCE: Two carers, a cook, a cleaner and the proprietor/registered manager were on duty at the time of the inspection. The inspector had access to the homes rota, which also confirmed the above. The registered manager advised the inspector that they had reviewed the staffing levels and now ensure that additional cover is available at busy times or when needed. At the time of the inspection staffing levels appear adequate. Six of the thirteen staff working at the home have completed the NVQ2 and four staff are currently on the course. The deputy manager in the home has completed the NVQ 4 and assessors course and this therefore enables the staff to receive adequate support and guidance whilst completing the course. It is envisaged that the home will meet the target of 50 of its staff being trained in NVQ2 by the end of 2005. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 18 The home has also provided training courses for staff in dementia care and medication since the last inspection. One member of staff had completed a course in infection control and the reduction of cross contamination. Some staff have not received training in areas relevant to their roles. This was discussed with the registered manager who agreed that the home would provide further training in the following areas, abuse, diabetes, moving and handling, skin care, basic food hygiene and health and safety. A requirement for staff training has been made. The home has policies and procedures in place to protect vulnerable adults. On speaking and questioning staff they displayed their awareness and understanding of the homes policies on reporting any issues that may be abuse and how to maintain privacy and the dignity of the service users living at the home. Staff displayed an excellent awareness of service user needs. Three staff files were audited by the inspector and found to contain all the relevant information. This included references and CRB and/or POVA checks for new staff. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 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): 31,33,35,36,38 Service users live in a well managed home, that is run for their benefit. Service users are consulted about the running of the home, however, this needs formalising. The home does safe guard service users monies. Some staff are supervised and appraised within their jobs, however, this needs further developing for all staff. Service users and staff are protected by policies and procedures, however, these need further development. EVIDENCE: Service users spoke positively about the home and the care they received. Service users confirmed that the providers and the homes staff are available in Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 20 the home almost every day and that the homes staff seek their views about the service it provides. Both service users and the homes staff confirmed that the home is managed effectively and that the registered manager/provider is excellent and runs the home for service users benefits. Staff advised the inspector that they are kept informed of any changes and that they are able to express their views openly. The home occasionally holds service user meetings and on a daily basis service users are spoken with to see if there are any issues. The meetings held had not been documented. Service users confirmed that staff act on their wishes and this was evidenced through menus, activities and how care is provided in the home. Service users are able to participate within the home and several service users help around their home as they wish. The home has started to seek the views of service users more formally, however, these are not documented. Service users spoken to confirmed that their views are listened to and that the home acts on their concerns. Following discussions with the proprietors and homes staff, the home does not seek the views of all stakeholders of the business. The home is required to formalise their monitoring of the quality of the service it provides. The home does not manage any service users money. The home had started to implement staff supervisions, which was found to be in the early stages. Some staff had received supervision and some staff appraisals had been completed. A requirement has been made. The home has undertaken a range of risk assessments, however, these need further developing to include any controls that may be necessary for any identified risks. The home has implemented some controls for identified risks including radiators, hot water, chemicals, falls, moving and handling. The home is to review its risk assessments and implement risk assessments for any further identifiable risks. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 x 2 Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 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 OP36 Regulation 18(2) Timescale for action Implement staff supervisions and 31/01/06 appraisals. This remains outstanding from the last inspection. Implement a suitable quality 31/01/06 monitoring system that takes into account the views of service users and other stakeholders of the home. This remains outstanding from the last inspection. Implement staff training 31/01/06 appropriate to service user needs. This remains outstanding from the last inspection. Undertake and document staff 31/01/06 risk assessments for the home. This must include the environment, specific jobs and any equipment used. Implement controls for any identified risks. Requirement 2 OP33 24 3 OP30 18(1) 4 OP38 13(4) Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 23 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 OP30 Good Practice Recommendations Obtain the support of relevant professionals for any training provided by the home. Rowan House DS0000011873.V255342.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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