Inspection on 11/07/06 for Rowena House

This inspection was carried out on 11th 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 House 02/07/08

Rowena House 04/07/07

Rowena House 10/10/05

Rowena House 26/04/05

Rowena House 10/11/04

Rowena House 20/07/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

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 Rowena House Old Road Conisbrough Doncaster South Yorkshire DN12 3LX Lead Inspector Ian Milner Key Unannounced Inspection 5th July 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 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 House DS0000032204.V301943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowena House Address Old Road Conisbrough Doncaster South Yorkshire DN12 3LX 01709 862331 01709 858383 NONE 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) Doncaster Metropolitan Borough Council Yvonne Margaret Lawson Care Home 36 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (24) of places Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Day care places in the DE(E) unit must be limited to 1 when the unit is full with 12 residential service users. There is insufficient communal space to meet the required communal space standard when the number of service users goes above this limit of 13 persons. An additional member of staff should be provided when the number rises above 12. 10th October 2005 Date of last inspection Brief Description of the Service: Rowena House is a purpose built care home situated on Old Road Conisbrough and owned by Doncaster Metropolitan Borough Council. It is on the main bus route and close to local shops and a public house. The town centre of Conisbrough is near by. The home is divided into two units with elderly mentally infirm living on the ground floor. Access to the first floor is via a lift and stairway. Rowena House is set in pleasant gardens and includes an internal courtyard equipped with garden furniture, where the residents and their guests are able to sit on fine days. There is parking for several vehicles to the front of the home. The home’s current fees range from £330.00 to £490.00 per week and information about fees is available to service users and their relatives in the ‘Welcome to Rowena House’ pack. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours. The inspection included reading residents’ care plans and other documentation, speaking to a number of service users, both individually and collectively, and to a range of staff. Relatives and carers visiting the home were invited to offer views on the care provided. The acting assistant manager and the registered manager assisted with the inspection. Lunchtime and teatime were observed. A tour of the home was undertaken with observation at different times of residents’ activities and of staff carrying out their duties. What the service does well: What has improved since the last inspection? The home has responded to the requirements and recommendations identified in the report of the last inspection. The monitoring and recording of water temperatures in bedrooms is carried out by a specialist firm and the current records of checks were examined during the inspection. The staff training programme now includes courses on prevention of abuse to adults and staff were identified for the course beginning in August 2006. The home now advertised locally for staff in addition to the Authority’s recruitment process. All service users and their relatives/carers have been provided with a copy of the Service User Guide which is undergoing some further development. User Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 6 surveys identified some uncertainty about complaint processes and this is being addressed. The key worker and staff supervision programmes have improved staff morale and working relationships. Staff reported a new cohesion in their working. 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 House DS0000032204.V301943.R01.S.doc Version 5.2 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 Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 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): 1, 3, and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and interviews with service users and relatives. Prospective service users are given good information to enable them and their relatives/carers to make informed choices about moving to the home. The Welcome to Rowena House’ pack together with other available information provides a good basis for those choices. Prospective service users and their relatives are able to visit, tour, and even stay at the home for a trial period before making decisions about admission. Care assessments carried out by senior staff before admission is decided offer a range of information about whether the home can need an individual’s needs. The resulting care plans are used on a daily basis to ensure that individual needs are being met on a daily basis by the activities provided. Intermediate care is not provided at Rowena House. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 9 EVIDENCE: The ‘Welcome to Rowena House’ pack including the Service User’s Guide and Statement of Purpose were examined during this inspection visit. The information about the home, its routines and its facilities was set out clearly for service users and their relatives/carers. One service user and her relative said they had studied it together carefully so that they understood clearly what was available and possible. In this way, together with invitations to view the home and spend time there, perhaps staying overnight, service users and their relatives/carers have a good level of information on which to base informed choices about a possible move into the home. Commission for Social Care Inspection reports were prominently on display in the home. A recent service user/relative survey had identified some uncertainty about complaint processes and this was being addressed through the key worker system and through more conspicuous use of leaflets throughout the home. A number of care plans were examined for evidence that service users and their relatives/cares contributed to care planning and were involved in decisions taken about care provided. It was clear that care plans are tools for daily living with good systems for their upkeep and development. Each service user’s care plan was considered at shift handover to ensure that activities and programmes were in line with assessed need. Service users and relatives/carers spoken to were unstinting in their praise of the effort made by staff members to motivate and involve service users. All those said it was like being at home. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are treated with respect and dignity, with their wishes about privacy being upheld. Each service user has a Health Care Plan with good systems and adequate protections in place to control medication and its administration. There was good evidence of close liaison between local GP’s and Health Services to ensure that service users’ health needs were kept under review and met accordingly. EVIDENCE: Many examples of good practice were observed during this inspection with staff dealing with service users in a respectful and thoughtful way. Staff were observed knocking on bedrooms doors and waiting to be invited in, and preferred names, evident on care plans, were used. Service users and relatives Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 11 spoken to said that they were happy with the care provided and of the attention paid to personal need and privacy. There was good evidence of close liaison with and between Health Service providers to address service users’ health needs. During the inspection the District Nurse visited and was observed treating not only those service users with ongoing conditions but providing advice and guidance to staff on other service users’ health issues. Service users could be visited by their GP in privacy in their own rooms. There was active consideration of how a dedicated treatment room could be provided. A small number of service users administered their own medication but there were good systems in place for the administration of medication and its safe storage. The records showed clearly who administered what medication to whom, and a random sample of records tallied with stocks held. A local pharmacy assisted with the monitoring of medication held and its appropriate shelf life. Staff spoken to who were responsible for the administration of medication had confidence in the systems in place. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The two units in the home had separate activity programmes which were coordinated by a member of the home’s management team but which service users could change or supplement through the service users’ weekly meeting. Service users spoken to were satisfied that the home’s lifestyle suited them. There was good evidence that staff encouraged service users to exercise choices and to maintain control over their lives. Visitors were welcomed at any time and staff actively encouraged family and friends’ contacts. There was a pride in the home’s part in the local community. Service users and their relatives spoken to complimented the quality and variety of meals available. Meal times observed were relaxed and convivial occasions. EVIDENCE: The home provides a good standard of accommodation with a range of communal lounges for either quiet activity or television and communication. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 13 Some service users were seen to read or watch television in their own rooms. Staff were observed spending time with residents in a range of board, craftwork and newspaper activities. The atmosphere was relaxed with service users doing what they wanted to do. Visitors spoken to said they were welcome at any time in the home and were made welcome with drinks and snacks. Two relatives spoke appreciatively of the extent to which the staff involved them in decisions about proffered care and activities There was evidence of religious preference s being observed with mainstream and minority religious groups offered facilities for worship with service users. Examination of Protection of Vulnerable Adult processes offered evidence of service users being strongly encouraged to exercise choice about family contacts and financial arrangements. Lunchtime and teatime were observed. The dining room was pleasantly set out and food was well presented. Service users spoke appreciatively of the quality and range of meals provided and alternatives and additional helpings were readily available. One service user who attended the home on a day care basis said that the meals were her lifeline. Staff discreetly and appropriately offered help to service users. The home was described as an integral part of its local community and the activities showed involvement in local community events and services together with community groups coming into the home. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints procedure which links to the Authority’s complaint processes. Information about the procedure is part of the ‘Welcome to Rowena House’ pack. Further work is required to make the procedure fully accessible to service users and their relatives/carers. Complaints made are taken seriously and acted upon. The home has a procedure for protecting service users from abuse and staff training has been arranged. EVIDENCE: The complaints procedure was examined. There was clear evidence that the complaints seen had been taken seriously and extensive efforts, in one case in conjunction with the service user’s relatives, had been made to try to resolve the complaint to the service user’s satisfaction. There was uncertainty that the number of complaints seen was the total number made since the last inspection. This was because there was no permanent log of complaints showing date complaint made, its substance, the efforts made to resolve it and its outcome. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 15 A recent service user and relative survey about the ‘Welcome to Rowena House’ pack had identified uncertainty about how to make and progress complaints. There was an increased emphasis on complaint leaflets in the home and keyworkers were being asked to focus attention on complaints and how to make them. Two service users made complaints to the inspector during the day about laundry/clothing issues and about the meal service. These complaints were taken to the manager who undertook to address them at once with keyworkers and with the service users’ weekly meeting. The home had policies and procedures about the prevention of abuse to service users and staff training had been prioritised in the home’s extensive training programme. The Protection of Vulnerable Adults process offered good evidence of multi-agency collaboration in specific matters where exploitation of service users by persons external to the home had been identified and addressed with clear safeguards put in place. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 16 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, 24 and 26. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home continues to offer a good standard of accommodation with a rolling programme of re-decoration and furniture upgrading which enhances the home’s safety for service users. The home appeared clean, pleasant and hygienic being free from adverse odours. EVIDENCE: The Statutory Requirement from the last inspection about the recording of safe water temperatures in bedrooms had been addressed by the Authority who had engaged a specialist firm to maintain and monitor the necessary temperatures. The records of the firm’s regular checks were examined. There was new carpeting and furniture in downstairs corridors, day rooms and the dining room. The rolling programme of re-decoration allowed for six Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 17 bedrooms to be re-decorated each year and service users were involved where possible in the choice of colours and fabrics. A downstairs bathroom recently adapted to provide a shower room has also had an additional toilet fitted Aids and equipment appeared to be in sound order with hoists and lifting equipment available as appropriate. There were handrails and grab rails in evidence. Service users were encouraged to personalise their bedrooms and many had personal furniture, photographs and possessions in evidence. Service users spoken to said they felt safe in the home. Domestic staff spoken to said that they were well equipped to keep the home clean and safe. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service and discussions with staff members. The staff team reflect a confidence in their work and showed good awareness of service users’ needs. The home has a recruitment policy and has acted to speed up recruitment to vacancies. EVIDENCE: Staff spoken to said that the keyworker and supervision programmes had improved communication between different staff teams and enabled previously divisive issues to be sorted out quickly. The new home manager was commended for addressing issues quickly and openly. The home has an extensive training programme seeking to improve staff skill levels in a number of areas, for example, training was being provided on Adult abuse, Valuing diversity, Infection, Movement and handling, Emergency aid, and First aid together with other care-based course. Within the last year there has been continued emphasis on NVQ Level 2. At the time of this inspection 46 of care staff were qualified to NVQ Level 2. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 19 The home has addressed the recommendation from the last inspection that there should be attempts to speed up recruitment. Although tied into the Authority’s recruitment policies and procedures the home is additionally advertising locally when vacancies arise. This has been effective. At the time of the inspection there were four vacancies, two of which were filled by longterm temporary appointments. At the time of this inspection the staff group was entirely female. The manager said that men have not traditionally applied for care vacancies in the home in the past but she is aware of the problem and is seeking to address it. Staff files examined by arrangement contained evidence of the recruitment process, of references sought before appointment, and of Criminal Records Bureau (CRB) checks. There was a process in place for renewing the CRB checks. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home appears to be well run by a manager who has the confidence of her staff group and service users. The management and administration of the home protects the health and welfare of the service users who live there. EVIDENCE: The manager has made a significant impact on the way in which the staff group interact with each other with a consequent effect on the care of service users. Staff spoken to were clear that the home is run for the service users. In their turn service users said that the manager makes Rowena House ‘just like home’ and were very appreciative of the staff group’s contribution to the care offered. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 21 There were clear procedures in force for safeguarding service users’ monies and a small number of random checks with staff showed that monies held tallied with records. Service users spoken to about money said that they knew how much they had and they were able to access it as and when they required. Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 22 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 X 3 X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 X 3 X 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 X 3 X 3 X X 3 Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 23 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 OP16 Regulation 22 Requirement The manager should provide a permanent log of complaints which shows the date of the complaint, details of the complainant, details of the complaint, actions taken to attempt resolution of the complaint, the complaint’s outcome and details of the complainant’s response. Fifty per cent (50 ) of care staff should achieve NVQ Level 2 by 2005. It is recognised that the home has almost achieved the requirement and remains committed to Standard’s demands. Timescale for action 31/10/06 2 OP28 18 31/12/06 Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 24 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 Rowena House DS0000032204.V301943.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 House DS0000032204.V301943.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!