Inspection on 22/11/05 for Rowena

This inspection was carried out on 22nd November 2005.

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 12/07/06

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 Unannounced Inspection 22nd November 2005 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.V267178.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. Rowena DS0000006965.V267178.R01.S.doc Version 5.0 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.V267178.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 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 detached property and has had some adaption 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 annd dentist are provided via the domicillary service every six months. Rowena DS0000006965.V267178.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection was undertaken over five hours in the presence of the Provider/Manager. Parts of the premises were inspected and the Policies and Procedures manuals viewed. During the course of the inspection the Inspector spoke with one relative and two member of staff. The home is registered to accommodated service users aged sixty five and over with a diagnosis of Dementia so their ability to contribute verbally to this inspection was limited. 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.V267178.R01.S.doc Version 5.0 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.V267178.R01.S.doc Version 5.0 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 Service Users and their representatives are given the information required to make a decision about Rowena. The Provider manager carries out the initial assessments of service users needs in order to assess whether they can be met at Rowena. EVIDENCE: The Home has a Statement of Purpose and a Service Users Guide. These documents gives the information regarding the care, facilities and services provided in order to make a decision about the suitability of the home. Care plans seen included the initial assessment completed by Care Managers. The Care plans are very comprehensive. Wherever possible Service users and or their representatives have the opportunity to visit the home prior to admission. Rowena DS0000006965.V267178.R01.S.doc Version 5.0 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 Care Plans are quite comprehensive with enough information for staff to meet the assessed needs of the service users. Medication records are adequately kept. EVIDENCE: Because most service users have the diagnosis of Dementia staff spoken to felt that it was difficult to involve them in the development of care plans. The home needs to develop a system that can involve the service user or their representatives in the reviewing of their care plans. The manager should when ever possible consult with the service user or a representative when revising care plans. (Req. 1) Medication is stored in a locked trolley. Medication records were examined in relation to the number of service users. These records were relatively well kept but there were a few gaps in the medication records. There are no service users that self medicate. Staff was observed speaking to the service users calmly and with respect. Service users were seen eating lunches and were wearing napkins Rowena DS0000006965.V267178.R01.S.doc Version 5.0 Page 9 appropriately. The meal was unrushed and service users that needed help were assisted. Rowena DS0000006965.V267178.R01.S.doc Version 5.0 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, 15 Service users can benefit from a more structured activity programme. Service users receive a varied nutritional diet. EVIDENCE: Activities are provided for service users but these could be more structured and varied. Family and friends can visit service users at any reasonable time. The relative spoken to stated that he was able to visit service user whenever he wished. If visiting is outside of meal times the service users and their relatives can meet in the dining area or their bedrooms if appropriate. Menus were inspected and found to be interesting and well balanced. A choice of food is offered at mealtimes. Bedrooms are personalised and the relative spoken to said he was able to bring in some personal possessions of the service user. Rowena DS0000006965.V267178.R01.S.doc Version 5.0 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): There are systems in place to protect service users from abuse. The home has a comprehensive complaints procedure. EVIDENCE: All staff have received training in the Protection of Vulnerable Adults. Staff are familiar with the home’s complaints policy. There was one complaint since the last inspection and this was reported to the Commission under Schedule 5. The complaint was fully investigated by Bromley Adult Protection unit and the outcome was that there was no evidence to support the complaint. The Manager of the home must ensure that staff training in adult protection is updated. (Req.2) Rowena DS0000006965.V267178.R01.S.doc Version 5.0 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, 23, 24,25,26 The home is reasonably well maintained and is free from odours. The home can benefit from more communal space for the service users. EVIDENCE: There is a large garden to the rear of the building, but the use of the garden is limited. There are plans to extend the Living Room to create more space for the service users. The home can benefit from the garden being more accessible and user friendly to encourage service users outside weather permitting. The registered person must ensure that the external grounds are suitable for, and safe for use by service users and appropriately maintained. (Req. 3) Rowena DS0000006965.V267178.R01.S.doc Version 5.0 Page 13 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 There are sufficient numbers of staff on duty to meet the needs of the service users. All staff should receive training to enable them to meet the needs of service users with dementia. EVIDENCE: A number of care staff are undertaking their NVQ training and most of the staff have received training in the administration and storage of medication and also Protection of Vulnerable Adults. The manager must ensure that staff who have not already done so, receive POVA training and staff are trained to enable them to meet the needs of service users suffering with dementia. (Req.4) Files seen had contracts, job descriptions, proof of identity, references and CRB checks. Rowena DS0000006965.V267178.R01.S.doc Version 5.0 Page 14 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, 36, 37, 38 The home is managed with the interest and safety of service users as a priority. EVIDENCE: The manager explained that she is present at the home most weekdays and when she is not she is only a phone call away. The Provider/manager lives fairly close to the home so there is always support for the staff. The Registered Manager is still undertaking her Registered Manager’s Award. The home’s policies and procedures were reviewed at this inspection and the Manager was able to produce a new manual that showed the policies and procedures of the home have recently been updated. The Inspector is unsure on how the manager ensures that staff are keeping up with the policies and whether they are being read and understood. Rowena DS0000006965.V267178.R01.S.doc Version 5.0 Page 15 Staff are being supervised every two months. A member of staff stated that she had received formal supervision. A sample of Health and Safety documents were examined and these were found to be up-to- date. Rowena DS0000006965.V267178.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 2 x x 3 3 3 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 3 3 3 x x 3 3 3 Rowena DS0000006965.V267178.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 15.2 Requirement The manager should when ever possible consult with the service user or a representative when revising care plans. The Registered manager must ensure that staff training in adult protection issues understand the concept and the potential abuse of service users The registered person must ensure that the external grounds are suitable for, and safe for use by service users are provided and appropriately maintained. The manager must ensure that staff who have not already done so, receive POVA training and staff and training to enable them to meet the needs of service users suffering with dementia. Timescale for action 31/01/06 2. OP18 13.6 31/01/06 3 OP20 232.o 31/03/06 4 OP27 18 (a) 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Rowena DS0000006965.V267178.R01.S.doc Version 5.0 Page 18 No. 1 Refer to Standard OP12 Good Practice Recommendations Service users will benefit from a more structured activity programme Rowena DS0000006965.V267178.R01.S.doc Version 5.0 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. 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