Inspection on 02/07/08 for Rowena House

This inspection was carried out on 2nd July 2008.

CSCI found this care home to be providing an Good service.

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 04/07/07

Rowena House 11/07/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Rowena House Old Road Conisbrough Doncaster South Yorkshire DN12 3LX Lead Inspector Christine Rolt Key Unannounced Inspection 2nd July 2008 09:25 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.V367339.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.V367339.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 Yvonne.Lawson@Doncaster.gov.uk NONE Doncaster Metropolitan Borough Council 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) 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.V367339.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. 4th July 2007 Date of last inspection Brief Description of the Service: Rowena House is a purpose built care home owned by Doncaster Metropolitan Borough Council. It is on the main bus route on Old Road in Conisbrough and is close to local shops and a public house. 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 outside. There is parking for several vehicles to the front of the home. The home is divided into two units. One unit is for the care of service users with dementia. The other unit is for the care of service users with personal needs. Access to the first floor is via a passenger lift and stairway. The home’s current fees ranged from £395.46 to 432.38 per week. Private chiropody and hairdressing were charged extra. The registered manager provided this information during the site visit on 2nd July 2008. Other information about the home is available in the ‘Welcome to Rowena House’ information pack, which includes the Service User Guide. Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9:25 am to 5:25 pm. The registered manager had completed an Annual Quality Assurance Assessment (AQAA). This document gave her the opportunity to say what the home did well, what had improved and what they were working on to improve. Various aspects of the service were then checked during the site visit. Care practices were observed, a sample of records was examined, a partial inspection of the building was carried out and service provision was discussed with the manager. The majority of people living at the home were seen throughout the day, and several were asked for their opinions of various aspects of the home and the care received. Three visitors were also asked for their opinions. The care provided for three people was checked against their records to determine if their individual needs were being met. Questionnaires were sent to 10 people who lived in this home. All opinions and comments were considered for inclusion in this report. The inspector wishes to thank people in the home, their visitors, staff, and the registered manager for their assistance and co-operation. What the service does well: The home had a good Quality Assurance system that ensured people’s opinions were considered and that systems were in place to protect them. Meals and dining facilities were excellent and showed that people were treated as individuals. People living in the home said that they were satisfied with their care and praised the staff, “Staff are very nice, very helpful. “Office staff, care staff very good. always willing to help” Always listen to you” Cleaners very good and kitchen staff Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 6 “I have no complaints about anything” and “I’m Happy”. 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. The summary of this inspection report can be made available in other formats on request. Rowena House DS0000032204.V367339.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.V367339.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using this service had full assessments of their needs. EVIDENCE: People said that they had sufficient information about the home. The home’s service user guide and latest inspection report were available in the main entrance. People spoken to said that this home was chosen because it was local to where they used to live. A person who lived in the home said that she used to visit the home when her mother had been a resident in the home and was happy to say that her mother “Celebrated her 100th birthday in this home.” Assessments were carried out and copies of the local authority assessments and the home’s own assessments were available on the three files that were Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 9 checked. wishes. These provided detailed information of each person’s needs and This home does not provide intermediate care. Rowena House DS0000032204.V367339.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were treated with respect. Medication recording procedures needed slight amendment. Care and health needs were met but care planning could improve. EVIDENCE: People living in the home looked well cared for, clean and appropriately dressed. They said they were happy living in the home. Staff were observed treating people with respect and kindness, and interactions were good. People said that they received the care and support they needed and were treated with respect and dignity. People said, “Never had any problems at all” “Sometimes a bit difficult at night time when limited staff around but I do have a buzzer to call them.” Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 11 “Do need some assistance with certain things due to eyesight” “All the staff are good” One person said that when her relative had returned to the home after a spell in hospital, she was impressed at how they had ensured that everything was in place for her return including the provision of a specialist mattress. Three care plans were checked in detail. Some care plans provided good details of the person’s needs and how the needs were to be met, whilst others provided very little information, therefore there was no consistency. Daily records gave information of health needs but no information on how people spent their days and physical needs were recorded as “needs met” without any details. There were activities sheets in the files but these were not completed consistently. The need for more holistic information was discussed with the manager who said that work had already commenced on updating people’s files to be more person centred. The care plans were reviewed monthly but there was no information to verify that people living in the home or their representatives were consulted. This was discussed with the manager. Files contained risk assessments. Accidents were recorded. The acting manager was advised to introduce 72hour monitoring sheets. These forms record the close monitoring of people who’ve had accidents or falls where no injuries are apparent at the time of falls and ensure that injuries are quickly noted. People said that their health needs were met. Relatives considered that they were kept informed of their relative’s wellbeing. The manager said that where people were capable of attending the GP surgery, they did so with an escort. This maintained people’s independence and encouraged them to continue to be part of the local community. This is good practice. One senior member of staff had overall responsibility for medication and carried out regular audits. Staff competency for dealing with medication was checked regularly and records were available. This is good practice. The medication was stored securely Medication tallied with the Medication Administration Record (MAR) sheets. Each medication was signed and dated on receipt and quantities were recorded. There were no gaps in the Medication Administration Record sheets. The senior member of staff said that all handwritten entries were countersigned, which is good practice. Some loose medication had not been carried forward onto the new MAR sheet. This must be done to ensure that a true record is kept. A record of staff signatures was kept. This is good practice. To promote staff awareness of people’s needs, and as a sign of good practice, the manager was advised to Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 12 ensure that all staff were aware of the reasons that people were on their prescribed medications including ‘as and when’ medications for pain relief i.e. what conditions the medicines were intended to treat, and to keep a record of this in their care plans. Controlled drugs were stored in a controlled drugs cupboard. The controlled drug register was checked. Medication was recorded properly with two signatures and a diminishing total. Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were satisfied with their lifestyles in the home. EVIDENCE: People were observed spending the day as they chose and considered that there was enough to keep them busy. Staff were observed and heard to offer choices, and one person described what they liked to do during the day. Information in care plans verified that people’s choices were taken into consideration. A notice board in the main entrance displayed a range of up and coming activities including a day trip. A copy of the weekly activities programme was also displayed in the Dementia Unit. People considered that there were always or usually sufficient activities available. Comments were, Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 14 “Bingo, entertainment, dominoes” “Enjoy bingo which we play. Would like to play more bingo.” At the time of this site visit, a group of staff had given up their time and were preparing to set off on a sponsored walk to raise funds for the home’s amenities fund. The manager said that this had become an annual event. Visitors said that they were made welcome. The dining room was clean and tidy. People living in the home said that they always or usually enjoyed the meals. A menu board informed people of the choice of meals and staff also went to each person and informed them of the choices for the next meal. Tables had tablecloths, condiments, gravy boats and dishes of vegetables so that people could help themselves to whatever they required. The meal was appetising. On the day of this site visit the main meal was gammon, new potatoes, green beans, cauliflower cheese and gravy. When people were asked if they liked the meals, their comments were, “Yes, definitely. Never had a bad meal all the time I’ve been here”, “They are always willing to find something I do like” “If I do not like the choices on the menu, cook/staff will always offer another alternative.” “Very nice.” Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People felt they were listened to and protected. EVIDENCE: The complaints procedure was seen and the complaints book was checked. People said that they knew how to complain and would tell a member of staff or the manager. Their comments were, “See person in charge”, “Staff always available, always ask if I’m ok”, “To the office staff”, “Would ask staff who would help me in the right direction”, “But I’m never unhappy” All staff had undertaken adult protection training and a member of staff confirmed that they had all recently attended the South Yorkshire Adult Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 16 Safeguarding event that launched the new South Yorkshire adult safeguarding procedures. The manager had notified the CSCI of an allegation of abuse. The correct procedures were followed, a full investigation made and the allegation was not upheld. Documentation relating to the incident was seen during this site visit. Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People lived in a clean and safe environment, but some areas could be made more attractive and welcoming. EVIDENCE: The home was clean and there were no offensive odours. Communal areas and some bedrooms had been redecorated. People said that they were satisfied with their rooms. However, some bedrooms had damaged wallpaper and chipped paintwork along skirting boards, some bedrooms were dark even though it was a sunny day and many of the bedrooms were not carpeted and had hard, washable flooring, which did not create a comfortable, domestic atmosphere. Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 18 The manager said that there was a rolling programme of redecoration and ten bedrooms had been prioritised for repainting. Bathrooms and lavatories were tiled. Liquid soap and paper towels were available to prevent cross contamination. Aids and adaptations were fitted throughout the home to maintain people’s independence. Within the dementia unit, lavatory doors were painted a different colour to help orientation so that people maintained their independence. Signs on doors and a display board in the dining room helped with orientation to time and place. An attractive internal garden area with raised flowerbeds was accessible from the dementia unit. Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were cared for by a well trained and dedicated staff team. EVIDENCE: There were sufficient staff on duty at the time of this site visit. People considered that the staff were good and treated people living in the home with respect and dignity. One person commented, “Never had a bit of trouble with staff here at Rowena.” The manager said that staff received Skills for Care induction training and National Vocational Qualification (NVQ) training was also promoted. She said that by the end of this year, 85 of staff would be trained to NVQ Level 2. A senior member of staff was responsible for organising and keeping records of staff training including mandatory health and safety training. (See next section for mandatory health and safety training.) All staff had undertaken Dementia Awareness training. Other training undertaken by various staff Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 20 included Equality and Diversity, Aggression and Violence, and Recording and Reporting. Observations throughout the day and information from the three care plans highlighted that many of the people living in the home had problems with their sight or hearing, therefore it was recommended that training in sensory awareness be considered to enhance staff skills. The recruitment files for three members of staff were checked. All contained the relevant checks and information including Criminal Records Bureau disclosures. Other correspondence was also available which showed that the system was robust. Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager promoted the welfare of people at the home, and it was run in their best interest. EVIDENCE: The registered manager had the relevant skills and experience and had achieved the Registered Manager’s Award. The home had a quality assurance system that included audits of systems and records within the home and safety checks of the environment. Residents’ meetings were held monthly, resident/relative meeting were held quarterly and questionnaires were sent out annually. The manager said the information was collated and analysed and an action plan drawn up. Results of the Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 22 questionnaires were fed back during the residents’ and relatives’ meetings. The home also had a suggestion box. The acting manager informed the CSCI of any incidents that affected people living in the home and the responsible person carried out visits to the home and produced reports. Money held on behalf of people who lived at the home was stored safely and individual account records were kept. A sample of these was checked and was correct. Receipts were available for purchases made on behalf of people living at the home and these were numbered and recorded on the accounts records for ease of reference when auditing. Records and certificates were available to verify that service and maintenance checks were carried out. A senior member of staff was responsible for keeping records of staff’s mandatory health and safety training (i.e. moving and handling, basic food hygiene, emergency first aid, infection control and fire awareness). This training was ongoing and a staff training matrix was available with dates of training undertaken and planned training dates. Senior staff had recently attained their First Aid Certificates. Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 23 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 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 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.V367339.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Timescale for action 27/08/08 2 OP7 15 3. OP9 13 Specific information of people’s identified needs and wishes must be provided for all people living in the home. Daily records must provide information of the needs that have been met at any particular time and state how the person spent their day (group activities, hobbies, one-to-one sessions etc) to provide more person centred care. Care plans must be reviewed in 27/08/08 consultation with the person or their representative, unless it is impracticable to do so Medication that is not returned 27/08/08 at the end of the month must be carried forward onto the new MAR sheet to ensure that a true record is kept RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 25 No. 1 2 3 4 Refer to Standard OP8 OP9 OP24 OP30 Good Practice Recommendations Implementing 72-hour accident monitoring sheets would ensure that injuries would be highlighted quickly where no injury was apparent at the time of a fall. Knowledge of why medications have been prescribed especially ‘as and when’ medications for pain relief would promote staff awareness of people’s health needs. Consider the improvements that can be made to bedrooms to make them more comfortable and domestic in character. Staff should be offered sensory awareness training to enhance their skills when helping people with sensory disabilities. Rowena House DS0000032204.V367339.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V367339.R01.S.doc Version 5.2 Page 27 - 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!