Inspection on 20/01/06 for Rowans The

This inspection was carried out on 20th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rowans The 21/08/07

Rowans The 31/08/06

Rowans The 04/03/05

Rowans The 12/10/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Rowans The West Ella Way Kirkella Hull East Yorkshire HU10 7LP Lead Inspector Diane Wilkinson Unannounced Inspection 20th January 2006 10:00 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 Rowans The DS0000019758.V261648.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. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rowans The Address West Ella Way Kirkella Hull East Yorkshire HU10 7LP 01482 659161 01482 653220 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) Humberside Independent Care Association Limited Mrs Jennifer Diane Taylor Care Home 53 Category(ies) of Dementia - over 65 years of age (53), Old age, registration, with number not falling within any other category (53) of places Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To take one service user under pensionable age Date of last inspection 16th May 2005 Brief Description of the Service: The Rowans is situated in Kirkella, a village to the west of the city of Hull. The home is registered to provide care and accommodation for up to 53 older people, including those with dementia. The home is owned and operated by the Humberside Independent Care Association Limited, which is a not for profit organisation. There is easy access to a wide variety of local shops, pubs and local transport. The accommodation is on one level and communal accommodation comprises of two shared bedrooms and 49 single bedrooms, some of which have en-suite facilities. Service users have the benefit of a number of lounges, a large dining room, open plan gardens and two small, enclosed courtyard areas. All areas of the home are accessible to service users. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of 7 hours, including preparation time for the inspector. The inspection of the home included a tour of the premises and examination of documentation, including care plans. The inspector spoke to three service users (one to one), the deputy manager and the registered manager (following the day of the inspection). A complaint received by the Commission for Social Care Inspection was investigated at the same time as the inspection. The complaint was received from an anonymous person stating that service users were locked in their bedroom overnight, and that a visitor was locked in a lounge with service users. The inspector found that some service users have requested that their bedroom door is locked during the night, and hold their own key. Lounges are locked overnight to prevent service users from leaving the home via the fire doors. The complaints were therefore found to be not upheld. What the service does well: What has improved since the last inspection? Care plans now include an individual needs assessment that is completed at the time of a service users admission. Care plans include information to show how a service user’s individual needs will be met – records evidence that care plans are reviewed on a regular basis. Controlled drugs are now stored correctly. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rowans The DS0000019758.V261648.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 Rowans The DS0000019758.V261648.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 Service user’s care needs are assessed and admission is only arranged when it is agreed that a person’s care needs can be met by the home. EVIDENCE: There is evidence that service users are assessed prior to their admission to the home and only admitted if it is felt that their assessed care needs can be met. Some care plans include pre-admission assessments and all include very detailed admission agreements. The deputy manager was reminded that, following assessment of a service user’s needs, a letter should be sent to them confirming that their current care needs can be met by the home. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Each service user has an appropriate care plan in place that is reviewed regularly, and these records evidence that health, personal and social care needs are met. The systems for the administration of medication are good but the lack of staff training could result in the lack of protection for service users. Service users and relatives report that privacy and dignity is respected at all times. EVIDENCE: Five care plans were examined by the inspector. All included a detailed assessment and care plan that records the specific needs of service users and how these should be met by staff. Monthly reviews of the care plan are recorded in service users’ files, although some of these have lapsed recently. The registered manager should ensure that these are recorded consistently. Each service user has a risk assessment in place that records their risk of falling, as well as mobility, nutritional, pressure care and night time/safety risk assessments. All care plans include a photograph of the service user concerned, apart from the records for two new service users, where the photograph is waiting to be printed. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 10 Weight charts are in place and there is a record of showers or baths taken. There is a record held for each service user of all contacts with GP’s and other health professionals, including very detailed reasons for the contact and any outcomes. These are kept separately to care plans for easy access, but ideally this information should be cross-referenced to care plans so that all information held about a person is in one location. A person’s continence care and pressure care is assessed and any changes are recorded in care plans. Appropriate pressure care equipment and continence equipment is secured for service users. A separate record is kept of any accidents occurring to service users – these are held with the record of contact with GP’s and other health professionals. There are appropriate policies and procedures in place for the handling, storage and administration of medication, including self-medication and the use of controlled drugs. At the last inspection the home were informed that they should treat Temazepam as a controlled drug. The inspector examined medication administration records and storage facilities and found that these are now satisfactory. There is evidence that tablets are counted on each occasion that they are administered and double signatures are recorded. There is a list at the front of medication administration records that gives the names of staff that administer medications. The inspector was concerned that one of these members of staff has received no medications training. This person must not administer medications again until basic medication training has been completed. All staff that administer medication have not received accredited training and this must be arranged as a matter of urgency. Service users reported that they are treated with respect and that their right to privacy is upheld. The inspector observed that staff knock on doors before entering, and service users confirmed that this does occur. Most service users have a single room so they are able to see visitors and health professionals in private. Some service users informed the inspector that they have requested a key to their bedroom door to prevent other service users from entering their bedroom. Service users reported that assistance with personal care is offered in a sensitive manner. Care plans include a service user’s preferred name. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 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): 13 and 14 Links with the local community are good and friends and relatives are encouraged to visit the home and are made welcome. Service users are supported to exercise choice and control over their lives within their capabilities. EVIDENCE: Care plans record any involvement with family and friends, and any visits from family and friends. Any visits out of the home by service users with relatives, friends or key workers are recorded in daily records. Some service users are taken to church by members of their church, and other service users are visited at the home by a priest or vicar. Service users are encouraged to take part in chosen activities – one member of staff works for two hours each weekday offering activities for service users, including one to one activities. These are recorded in the ‘activities book’ rather than in care plan records. As previously indicated, it would be advisable for this information to be cross-referenced to care plans. Activities include movement to music, bingo, dominoes and ‘memory time’. Individual social care assessment forms were seen by the inspector. Some service users informed the inspector that they have newspapers and magazines delivered to the home. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 12 There is evidence that service users are supported to exercise choice and control over their lives, within their capabilities. The inspector spoke to one service user who goes out of the home unaccompanied almost daily, usually for a walk locally. They inform the home of the time they are expected back, in case of emergencies. Service users are asked if they would like a key to their door, and service users are able to have meals in their bedrooms if they prefer. Some service users that are assisted with meals by staff remain in one of the lounges to eat their meals. Service users are assessed regarding their wishes and capabilities for selfmedicating and managing their own financial affairs. One service user commented ‘staff make no attempt to restrict my independence’. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 There is a satisfactory complaints procedure in place and evidence that service users and others know how to complain. Staff are aware of and follow policies and procedures that are in place to protect vulnerable service users from abuse. EVIDENCE: The complaints policy has been amended and now records that complaints can be referred to the Commission for Social Care Inspection at any stage. The complaints log was examined by the inspector and complaints were found to be investigated appropriately and records kept accordingly. An analysis of complaints received from 1.7.05 to 30.9.05 was seen by the inspector. Training records evidence that most care staff have attended the protection of vulnerable adults training – this is considered to be mandatory training by the organisation. Some staff have also undertaken training entitled ‘Understanding Dementia’. There are appropriate policies and procedures in place, including whistle blowing, dealing with aggression and protecting service user monies. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: None of the above standards were assessed on this occasion, but the inspector noted that there were unacceptably strong odours in some areas of the home. These must be addressed as a matter of urgency. The inspector also noted that one shower room and one bathroom were out of order – five bathrooms remain in use and the deputy manager informed the inspector that this was sufficient to meet the needs of the current service users. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 Staffing levels ensure that service users are safe, and that the premises are clean and hygienic. Appropriate staff training is taking place to ensure the health, welfare and safety of service users, although more priority needs to be given to training that leads to NVQ qualifications. EVIDENCE: The staff rotas were examined by the inspector – these record the role of staff, including ancillary staff. The ‘standard’ rota includes six care staff am, five care staff pm and three care staff overnight. This level is maintained whenever possible. Managers, housekeeping, administrative, maintenance, catering and other ancillary staff are employed in addition to care staff. One service user has been given funding for one to one care between the hours of 8.00 am to 10.00 pm and these hours are recorded on the staff rota. Between 20 – 25 of care staff employed at the home have achieved NVQ Level 2 or 3 in Care and two staff are currently undertaking this award. Two care staff that had achieved the award have left the home. There must be an action plan in place that records how the requirement for 50 of staff to complete this award will be achieved. The inspector was informed that all staff now enrol for NVQ training on completion of their Induction training. New staff are required to attend a full week of Induction training with the organisation. Training programmes evidence that an induction training programme is held every month. There is an individual record for each Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 16 member of staff recording the training that they have undertaken. The organisation produce a list of training that they consider to be mandatory, and which group of staff should undertake each training programme. A monthly programme is sent to each home in the organisation recording the names of staff who are required to attend training courses that month. There is also a list of when the organisation considers that training should be repeated, for example, every two years or every three years. Records evidence that staff have an annual training and development assessment, and this includes a selfassessment to be completed by staff. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 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 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): 31and 33 The home is being managed effectively. The quality assurance system enables service users and other stakeholders to affect the way in which the home is operated. EVIDENCE: The home is managed by an experienced, competent and qualified member of staff. The registered manager has achieved the NVQ 4 Registered Manager’s award and holds the Certificate in Social Services, a social work qualification. The registered manager keeps her practice up to date by attending refresher training with other staff, and attends care conferences. The registered manager assists the organisation to present its training programme. Managers in the organisation meet together to ensure that they keep up to date with current good practice guidelines and changes in legislation. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 18 There is a QA year plan in place. This records a timetable for surveys to be sent out to service users, relatives and staff, for information to be collated, any shortfalls noted and feedback to be given to participants. This information leads to the development of an annual service review to be used for the purposes of retaining the Quality Development Scheme (the local authorities quality scheme). Results of relatives, staff and service user surveys include areas that need to be ‘worked on’. The timetable for January – March 2006 records ‘1. review QA for the year, 2. develop next year’s QA plan, 3. complete annual service review for QDS’. The inspector recommends that other stakeholders, such as health and social care professionals, are included in these quality surveys. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 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 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 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X X Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement Timescale for action 20/01/06 2 OP9 13 The member of staff that has had no medication training must not administer medication until basic training has been undertaken. All staff that administer 31/03/06 medication must undertake accredited training as a matter of urgency. 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 Refer to Standard OP3 OP7 OP33 Good Practice Recommendations At the time of admission, written confirmation should be sent to service users stating that their current care needs can be met by the home. Monthly reviews of the care plan should be consistent. It is recommended that health and social care professionals are included in quality assurance surveys. Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Rowans The DS0000019758.V261648.R01.S.doc Version 5.1 Page 22 - 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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