Inspection on 13/04/06 for Rowan Lodge

This inspection was carried out on 13th April 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

Rowan Lodge 09/08/07

Rowan Lodge 09/01/07

Rowan Lodge 10/11/05

Rowan Lodge 29/04/05

Rowan Lodge 15/10/04

Rowan Lodge 14/05/04

Rowan Lodge 14/10/03

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

CARE HOMES FOR OLDER PEOPLE Rowan Lodge 36 Keble Close Northolt Middlesex UB5 4QE Lead Inspector Ms Jean Bovell Unannounced Inspection 13th April 2006 11:20 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 Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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 Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rowan Lodge Address 36 Keble Close Northolt Middlesex UB5 4QE 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) 0208 423 9095 020 8423 9095 Mr Ramnarain Dyanan Sham *** Post Vacant *** Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0), Old age, not falling within any other category (0) Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Accommodation on ground and first floors only. Date of last inspection 10th November 2005 Brief Description of the Service: Rowan Lodge is a care home providing support for three older people, who are over sixty-five years of age, and have past or present mental health needs. All of the current service users are female. The home was first registered in 1991. The Registered Provider owns another larger home in Harrow. The home is situated in a quiet road in Northolt and there is easy access to local shops and to a bus route. The accommodation for the service users consists of a goodsized lounge/dining area, a kitchen and a small utility area on the ground floor. Two bedrooms are located on the first floor and one bedroom is located on the ground floor. There is a small paved area to the front of the home and a goodsized garden to the rear of the house. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 11.20 am and 2.50 pm on 13th April 2006. Two members of the care support staff team – one on each shift - and one service user were present. The Inspector was informed that two service users were attending the day centre. During the course of the inspection, a tour of the building was undertaken, the home’s records, policies and documents were viewed and observations were made. The Inspector spoke to two care support workers and one service user. The requirements that were made at the last inspection were examined and all key standards were inspected. The Inspector received appropriate co-operation and assistance from a care support staff member and subsequently from the Registered Provider who visited the home during the inspection. What the service does well: All records inspected were satisfactorily kept and up to date and were indicative of the health, safety and welfare of the service users being protected at the home. The Inspector spoke to two members of the care support staff team who reported being satisfied with the training and support they received at the home. This was evidenced on training and supervision records viewed during the inspection. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 6 A service user who was present throughout the inspection appeared well cared for, appropriately dressed and comfortable within his/her environment. The service user reported being happily settled at the home. Overall the home was found to be clean, hygienic and generally well maintained. The atmosphere was calm and homely. What has improved since the last inspection? 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 Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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 Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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): 3 and 6. Appropriate needs led assessments are carried out in relation to prospective service users and they receive clearly written confirmation of the home’s capacity to meet specific assessed needs prior to admission. EVIDENCE: It was evidenced on service users’ files that comprehensive initial needs led assessments had been carried out prior to admission and that relatives, social workers and medical professionals participated in assessment processes. Copies of documents/contracts detailing how the home would meet the specific needs of new service users were seen within individual files and all contracts were appropriately signed. The home’s service users’ guide and statement of purpose contained all the required information under the Standard and were clearly and appropriately written for meeting the needs of the service users. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 9 Intermediate care is not provided at the home. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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. The personal and health care needs of the service users are appropriately met and their privacy and dignity are being respected. The home has satisfactory medication systems in place. EVIDENCE: The specific health, personal and social care needs of the service users were reflected on their individual care plans. Action plans and set goals were put into place and appropriate risk assessments had been undertaken. All care plans and risk assessments were reviewed on a monthly basis. The home’s policy and procedures on medication were in place and the records were reflective of medication training being delivered to all members of the care support staff team. The storage, disposal and administration of service users’ medicines were inspected and found to be satisfactory. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 11 The Inspector was informed by the Registered Provider that none of the service users were self administering their medication at the time of the inspection. It was indicated on records viewed that service users received annual dental and optical checks. There were regular visits from the CPN. Service users received access to a general practitioner or chiropodist as required and were escorted to hospital appointments. A care support worker confirmed that service users received assistance with personal care in their separate bedrooms or within bath/shower rooms. Service users were also able to make or receive private telephone calls and personal mail was handed to them unopened. Separate locks had been fitted onto service users’ bedroom doors and each bedroom contained a lockable cabinet. Service users also chose and wore their own clothes at all times. A service user who spoke to the Inspector indicated that she was treated with respect at the home. Care support staff members who were on duty at the time of the inspection were observed to relate to a service user in a sensitive and respectful manner. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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. Contact with relatives and friends are satisfactorily encouraged and facilitated and the choices given to service users are appropriate in relation to their needs. Varied and nutritional meals are being provided to the service users. Two requirements made under Standard 12 at the last inspection, remain outstanding. A requirement under Standard 15 had been met. EVIDENCE: Two requirements that were identified under Standard 12 at the last inspection had not been complied with. These related to service users being given opportunities for participating in activities within the community including visits to local churches. A service user who spoke to the Inspector reported that a piano player visited the home on a Tuesday and that service users attended a day centre each Thursday. A significant period of time was spent sitting in front of the television as out door activities were rarely organised and service users were not encouraged or enabled to attend local churches. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 13 The above assertions were discussed with the Registered Provider. He explained that the service users expressed no interests in participating in activities within the community or attending religious services but said that the situation would be reviewed. The Inspector was informed by the Registered Provider that contact with relatives and/or friends were encouraged and facilitated at the home. A service user told the Inspector that he/she received regular visits from relatives and occasions such as birthdays and Christmas were spent with relatives in their own home. It was indicated on records viewed that one service user handled his/her own finances. Service users are able to bring personal possessions such as photographs, television sets or specific items of furniture to the home and this was reflected in individual bedrooms viewed during the inspection. Contact details of agencies that may represent the best interests of the service users are contained within the service users’ guide and the Registered Manager confirmed that – if requested - service users or their next of kin would be given access to individual personal files. There was plenty of dried, frozen and fresh food including fruit and vegetables at the home. Varied and wholesome meals were listed on the menu and complied with a requirement made under Standard 15 at the last inspection. A nutritious cooked meal was offered to a service user during the inspection. A service user expressed satisfaction with the quantity and quality of food served at the home and reported that snacks and drinks were readily available. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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. The home’s complaint’s procedure is adequately detailed and service users are satisfactorily protected from abuse. EVIDENCE: The complaints procedure was clearly written and easily accessible to service users and their relatives. No complaints had been made to the home since the last inspection. The home’s policy and procedures on Adult protection and the London Borough of Ealing Manual on the Protection of Vulnerable Adults were in place. It was reflected on training certificates that training on the protection of vulnerable adults was delivered to the members of the care support staff team. Staff members who spoke to the Inspector indicated knowledge of the policy relating to whistle blowing. Financial records relating to the personal allowances of two service users were examined and no discrepancy was identified. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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, 21, 22, 24 and 26. A clean, safe and homely environment is being provided to the service users and the bathroom and toilet facilities appropriately meet their personal needs. However, repairs are required to two taps in one of the bathrooms. Requirements made under standard 22 and 24 at the last inspection had been met. EVIDENCE: The communal areas within the home are adequately spacious, comfortably furnished and suitable for shared and/or individual activity. The garden was tidy and easily accessible to the service users. Additional grab rails for assisting the service users were fitted in the bathrooms in compliance with a requirement under Standard 22 at the last inspection. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 16 The bathroom and toilet facilities were sufficient for meeting the private and personal needs of the service users. However, repairs were required to two taps in the bathroom on the first floor of the building. The service users’ bedrooms were recently redecorated and contained new furniture. A service user reported being consulted regarding colour schemes and choice of furniture and was happy with his/her newly decorated bedroom. This met with a requirement under Standard 24 at the last inspection. The hallway and communal areas were in the process of being decorated at the time of the inspection. Overall, the home was found to be clean, hygienic and generally well maintained. The environment was safe, comfortable and calm. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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. The care support staff members are appropriately trained for meeting the needs of the service users but the current minimum staffing levels should be reviewed. The home’s recruitment policy and practices ensure that the service users are satisfactorily supported and protected. A requirement made under Standard 27 at the last inspection had been complied with. EVIDENCE: The staff rotas were fully completed and up to date. This complied with a requirement at the last inspection. It was indicated on the staff rotas that five care support workers were employed at the home. One care support worker covered duty on each shift during waking hours and there was one sleep-in cover at night. The current minimum staffing levels should, however, be reviewed to ensure adequate support for service users who may wish to participate in activities within the community. The home does not employ a cook or cleaner and the care support workers are responsible for carrying out these duties. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 18 There was recorded evidence that new staff members received Topps-certified induction training. The Inspector was advised by the Registered Provider that two care support workers had obtained National Vocational Qualifications in levels 2 and 3 and that three care support workers were receiving National Vocational training at the time of the inspection. A number of training certificates were viewed and confirmed that appropriate training for meeting the needs of the service users was delivered to all members of the care support staff team. This included, POVA, medication, mental health awareness, diabetes, dementia, food hygiene, first aid and moving and handling. The personnel files of two members of the care support staff team were examined. Each file contained all the required documents such as application forms, references, proof of identity, CRB clearances and signed contracts/statement of terms and conditions. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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 and 38. The home does not have a Registered Manager which is not satisfactory and this situation must be resolved as a matter of priority. Appropriate quality assurance systems are in place at the home and the service users financial interests are being satisfactorily protected. Although the health, safety and welfare of the service users are adequately safeguarded, fire safety checks should be regularly undertaken and recorded. EVIDENCE: The Registered Manager’s post was vacant at the time of the inspection but the Inspector was advised by the Registered Provider that the vacancy would be filled by an identified senior member of the existing care support staff team. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 20 It was evidenced on documents viewed that effective quality assurance systems were in place and that the views of service users, relatives and stake holders were being sought. The financial records relating to service users’ personal allowances were satisfactory. Receipts were in place and corresponded with outgoing expenditure. All cashed monies were securely kept. The records indicated that the gas boiler, central heating/hot water and electrical systems were regularly maintained. Tests for legionella had been undertaken. However, regular fire safety checks and fire drills were not evidenced on records viewed at the time of the inspection. Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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 X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 3 X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 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 OP12 Regulation 16(2)(m) (n) Timescale for action Service users must be enabled to 30/05/06 participate in activities in the local community. This is restated from the last inspection, previous time scale 01/01/06. Service users must be enabled to 30/06/06 maintain their religious beliefs and attend local churches if they so wish. This is restated from the last inspection, previous timescale 01/01/06. The Registered Person must ensure that all taps at the home are maintained in good working order. The Registered person must ensure that staffing levels are appropriate for supporting service user participation within the community. The home must have a Registered Manager in post. The Registered Person must ensure that fire safety checks are regularly carried out and DS0000027762.V289552.R01.S.doc Requirement 2. OP12 16(3) 3. OP21 23(2)(c) 30/05/06 4. OP27 18(1)(a) 30/06/06 5. 6. OP31 OP38 8 (1) (a) (b) (iii) 23(4)(a) 30/06/06 30/05/06 Rowan Lodge Version 5.1 Page 23 recorded. 7. OP38 23(4)(e) The Registered Person must ensure that fire drills are regularly undertaken and recorded. 30/05/06 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 Rowan Lodge DS0000027762.V289552.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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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