Inspection on 12/07/06 for Rowena

This inspection was carried out on 12th July 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

Rowena 21/08/07

Rowena 22/11/05

Rowena 17/05/05

Rowena 27/01/05

Rowena 24/05/04

Rowena 04/03/04

Rowena 05/12/03

Rowena 14/10/03

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

CARE HOMES FOR OLDER PEOPLE Rowena 28 Oakwood Avenue Beckenham Kent BR3 3PJ Lead Inspector Cheryl Carter Key Unannounced Inspection 12th July 2006 09:30 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 Rowena DS0000006965.V294035.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. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rowena Address 28 Oakwood Avenue Beckenham Kent BR3 3PJ 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) 020 8650 3603 020 8650 3603 Mr Cader Mrs Bibi Cader Mrs Bibi Cader Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: Rowena is a residential care home located in a residential area of Beckenham. The home has been registered to the current owners since March 1995 and provides accommodation for up to 22 persons in the category of Dementia. The home is a detached property and has had some adaptations in order to make it more accessible to the service users. A passenger lift links the ground and first floor accommodation. There is a large lounge and dining room where service users are able to spend time with each other, watch television and participate in various activities and welcome friends and relatives. In addition there is a large garden where service users can sit out in the warmer weather. The Home provides staffing throughout the 24-hour period .Mrs Cader is the Registered Manager. Support services are offered via the Local Primary Care Trust including the GP and district Nursing Services. The chiropodist, optician and dentist are provided via the domiciliary service every six months. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The inspection was carried out over six hours. The inspector spoke to three service users, three members of staff and one relative who was visiting at the time of the inspection. The visitor was very pleased with the care her mother was receiving and felt that her mother was happy and settled at the home that was unlike the previous home she had been in. The inspector met with the manager, a tour of the building, including communal areas and bedrooms, kitchen and laundry areas were made. Care plans and medication documentation were inspected. Staff records were also inspected. What the service does well: 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. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 6 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 Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 7 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, 3, 4, 5, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered provider assess the prospective service user either in their own home or in hospital to ensure that the service can meet their needs. Information relating to these assessments was evident on the files tracked. EVIDENCE: The home has a Statement of Purpose and a Service User’s Guide but both these documents have been updated. Three service users case files were tracked as part of the visit to the service. Terms and conditions of residency were on the files and the room to be occupied was specified. The assessment carried out prior to moving in underpins the service user’s care plan. The registered manager must ensure that all residents are appropriately assessed prior to admission and the home must confirm in writing its ability to meet the service user needs. (Req.1) No service user is referred solely for intermediate care. . Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 8 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, 10, 11 Quality in this outcome area is good. The judgement was made using available evidence including a visit to this service. Care plans and risk assessments are detailed and reflect the needs of residents. EVIDENCE: The inspector examined four care plans of service users. The home uses a booklet titled Assessment for Good Care Planning. This is a comprehensive document that contains every aspect of the service user’s care. It gives a personal profile of the service user and contains Mental Health, physical health, Nutrition, Behaviour, pressure sore and Nutrition Screening assessments. There are also risk assessments for falls and Service User ‘s Needs and preferences. This underpins the care and action plan of each service user. There are also six monthly or yearly reviews included in the booklet. There are no service users who currently administer their own medication. A system for reviewing risk assessments should be developed. Medication systems were inspected and the inspector noted that there were photographs of service users on each chart. Nearly all the staff have received Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 9 training in the safekeeping, storage and administration of medication. Only staff with this training is allowed to give out medication. The Registered Manager should keep a record of this training and how often it needs to be updated. Information in case of their death is included in their care plans. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 10 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, 15 Quality in this outcome area is adequate. The judgement was made using available evidence including a visit to this service. Residents have choices in their day and are encouraged to take part in the activities in the home. EVIDENCE: Friends and relatives are encouraged to visit and there is an open visiting policy where visitors are allowed in the home at any reasonable times during the day and evening. Service users have a choice of dishes at mealtimes. Lunch was served in the dining room and the tables were nicely set with brightly coloured tablecloths. Service users who needed assistance with feeding were assisted in an unrushed manner. There were some in-house activities but this is very limited. The registered manager informed the inspector that with the responsibility for activities now allocated to a specific worker the programme will be improved. The Registered Manager should have a table of activities for service users. Service users have the opportunity to choose what they want of the menu each day. The use of visual aids in the home displaying the day date, and weather and visual aids relating to the menus is recommended. (Recommendation 1) Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 11 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 Quality in this outcome area is adequate. The judgement was made using available evidence including a visit to this service. There is an appropriate complaints procedure. EVIDENCE: There were no complaints recorded since the last inspection. The inspector recommends that all staff receive training complaints, and how to record complaints. The registered manager must ensure that all complaints regardless of how trivial are recorded with the date of the complaint the action taken and outcomes of the complaints. (Req. 2) Accidents were appropriately recorded in the accident book. Staff have received training in the Protection of Vulnerable abuse and staff interviewed were able to say how they will respond if they suspect abuse. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 12 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, 26 Quality in this outcome area is good. The judgement was made using available evidence including a visit to this service. The environment was clean and well maintained that meets the needs of residents and allows them to reside in a homely environment EVIDENCE: There is a programme of refurbishment and maintenance both internally and externally on-going at the home. The registered provider is currently considering phasing out the shared rooms as they become vacant. The main lounge is being extended and the access to the rear garden is being made more users friendly. Service users are encouraged to personalise their rooms. All areas of the home were clean and there was no evidence of any unpleasant odours. There are sufficient toilets and bathrooms to meet the needs of the service users. Bedrooms were personalised: they had photographs, ornaments and personal items. Window restrictors were in place ensuring the safety of service users. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 13 The kitchen was reasonable and the cupboards and work surfaces appear to be in good condition. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 14 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, 30 Quality in this outcome area is good. Staff files were complete with the required documentation on file. EVIDENCE: The staff team consists of care staff, domestic staff and a cook in order to ensure that the resident’s needs were met appropriately. The rotas seen at the time of the inspection indicated that there are always sufficient numbers of staff on duty to meet the needs of residents. Six staff members are currently undertaking the Level 2 NVQ. The Deputy Manager has a Level 3 NVQ and the Registered Manager/provider has almost completed her Registered Manager’s Award. Staff files for four members of staff were seen and all were in order. Evidence of references and enhanced CRBs and proof of identification were on file. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 15 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, 34, 35, 36, 37, 38 Quality in this outcome area is good. The judgement was made using available evidence including a visit to this service. The home provides opportunities for staff and residents to inform the owners and manager of their views regarding the home. Staff is supervised in line with the National Minimum Standards. EVIDENCE: The provider/manager is a qualified nurse and is undertaking the Registered Manager’s Award. The inspector observed staff engaging with service users to offer drinks and to assist with feeding. The home has a quality assurance questionnaire that has been filled in by service users and their families. However the results of this questionnaire need to be collated and a report sent out to the service users and the Commission. Fire safety equipment has been tested and as required. Staff evidence being provided with regular fire safety training. Servicing records relating to the lifts and hoists were also seen. Hazardous substances were stored securely. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 16 The registered manager/provider has a financial and business plan that includes the refurbishment and the extension of the main lounge. Insurance is in place and a variety of Health and Safety documents including the Fire drills and, gas, electricity and portable testing appliances were seen. All of these were up to date. The care staff is supported with supervision every 8 weeks by the manager. The inspector spoke with three members of staff and they confirmed that they were having regular supervision. Staff describes the manager as being easy to talk to and they appeared happy in their jobs as carers. One member of staff said she was pleased to be doing the level 2 NVQ. Service users files are stored in locked cabinets. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 17 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 2 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 18 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 OP3 Regulation 14 Requirement The Registered Manager must ensure that all residents are appropriately assessed prior to admission and must confirm in writing that the home’s ability to meet the service user’s needs. The registered manager must ensure that all complaints regardless of how trivial are recorded with the date of the outcome. Timescale for action 29/09/06 2. OP16 22.3 29/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP14 Good Practice Recommendations The use of visual aids in the home displaying the day date, and weather and visual aids relating to the menus is recommended. Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Rowena DS0000006965.V294035.R01.S.doc Version 5.1 Page 20 - 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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