Inspection on 02/03/07 for 12 Queens Terrace

This inspection was carried out on 2nd March 2007.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

12 Queens Terrace 13/09/07

12 Queens Terrace 22/11/05

12 Queens Terrace 01/03/05

12 Queens Terrace 19/08/04

12 Queens Terrace 11/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 12 Queens Terrace 12 Queens Terrace Fleetwood Lancashire FY7 6BT Lead Inspector Mrs Jennifer Dunkeld Unannounced Inspection 2 March 2007 10:00 nd 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 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 12 Queens Terrace DS0000009984.V323521.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 Adults 18-65. 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. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 12 Queens Terrace Address 12 Queens Terrace Fleetwood Lancashire FY7 6BT 01253 876386 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) Ms Maria Elizabeth Gilchrist *** Post Vacant *** Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider must provide an en-suite bathroom in the first floor front bedroom prior to admitting a new service user to this room. The service user currently occupying this room must have exclusive use of one of the two bathrooms. 22nd November 2005 Date of last inspection Brief Description of the Service: This home is situated on the promenade at Fleetwood overlooking the port. It is situated in close proximity to local amenities including shops, public transport and public houses. It is registered to accommodate four adults who have a learning disability. All accommodation is single with one bedroom being provided on the ground floor and the other three on the first floor. There are two bathrooms on the first floor. There are two lounge areas, a dining room and a dining kitchen. The laundry facilities are situated in the basement. At the rear of the property there is a large garden. The current fees ranges of fees were not available at the time of this visit. The Pre Inspection Questionnaire completed by the service provider states in relation to fees ‘Social Services determine package of care’ 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has been inspected against the National Minimum Standards for Adults introduced in April 2002. This inspection was unannounced in that neither the residents or service provider and staff were aware the inspection was to take place on 2/3/07 at 10am. In the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small group of residents. All records relating to these individuals are examined, along with the rooms they occupy in the home. Residents are invited to discuss their experiences of the home with the inspector; this is not to the exclusion of the other residents who contributed in many ways. This inspection included discussion with the two staff on duty, a senior carer and a new member of staff. The service provider who manages the home on a day-to-day basis was off sick due to bereavement. The inspection also included observing the residents and the positive manner in which they were being cared for. The home’s required written information such as the resident’s plans of care were viewed. Each resident has a written plan of care, which is a document outlining the needs of the individual resident and how these are to be met. They cover all aspects of the individual’s life including health, personal care and social activities. Thereby ensuring people are content in the care they receive. The staff spoken with enjoyed their work at Queens Terrace and spoke in a professional manner about the residents. The residents appeared happy in their home and were seen to be well cared for. One man was happily walking around the home and every now and then came to see what the senior carer and I were doing. The residents were about to get ready to go out for lunch when I arrived to carry out the site visit. This had an impact on the length of time I felt able to spend in the home but did not prevent obtaining the necessary information to write this report and ensure the residents were being well cared for and having their needs met. It is apparent that the home is run around the needs and wishes of the residents, with staff who are keen to ensure the residents are not disappointed by having their plans for the day disrupted. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The recent progress of some staff working towards a relevant care qualification is helping them to offer a good quality of service to the residents. I suggest that the service provider upon her return to work continues to work towards achieving the Registered managers Award so that she has the skills to make sure this care home is managed to a good standard. This will mean that staff can benefit from her leadership\and the residents are comfortable living in a home that is well managed. The service provider needs to ensure that medication is securely stored in order to prevent any possible incidents of medication being wrongly taken. The medicine cabinet key should not be left accessible to others. The practice of having all financial transactions of resident’s monies held for safe keeping by the home, witnessed and signed by 2 people wherever possible should be adopted. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 7 The development and use of a staff application form would enhance the homes current recruitment process. 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. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. No-one is admitted to the home without being assessed thereby ensuring the home can meet their needs and wishes. EVIDENCE: There have been no admissions since the last inspection 22/11/05. However the senior member of staff stated that people would be assessed prior to admission to ensure the home could meet the needs of the individual. The Pre Inspection Questionnaire completed by the service provider reflected that there was a pre admission assessment format and this was seen at the time of the inspection. The homes Statement of Purpose reflects that all prospective residents would be assessed prior to admission to ensure the home is able to meet the individual’s diverse needs. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service provider and staff team continue to make sure the needs and personal goals of people are met by having clear care plans for all individuals. EVIDENCE: The case tracking process revealed that there have been no changes regarding the care plan process since the last inspection. They continue to be reviewed regularly with full consultation with the service user. They include details of mobility, communication, health, diet and medication. A new member of staff told the inspector that the care plans had been a good source of information for finding out about the level of assistance each person requires and that they reflected practice in the home. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 11 Risk assessments are in place to make sure people are safe, and these address areas such as chopping food, using taxis and using stairs. The home cares for male and female residents and recognises equality for people choosing a care home. While some of the residents do not have the skills to communicate verbally, the staff have got to know them well and can quickly pick up when someone is not happy. For instance one man had lost his favourite baseball cap and appeared anxious. The staff quickly found his cap and he returned to appearing happy again. One resident was at a day centre that she likes to attend. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management support people to maintain their place in the community and keep contact with family and friends and have a fulfilling lifestyle, the residents’ benefit from this. EVIDENCE: Staff stated that the good contact is maintained with families and that the service provider has recognised the importance of this. She liaises with families on behalf of those who cannot communicate themselves. The comment cards completed by relatives include the following comments, ‘I can only hope that every place is as good. I am elderly and not afraid of dying 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 13 because he is so well cared for.’ And ‘Maria (service provider) will phone me and discuss things and I know will always listen to me.’ There were photos of residents and their family in the home which added to its homely appearance. The residents appeared well nourished and menus reflect a healthy balanced diet. Some residents were going out to their bank and for a meal out on the day of the visit. Another resident was at a day centre for her day occupation. The staff spoke about holidays that the residents enjoy to destinations of their choosing. The staff stated that the residents are enabled and encouraged to maintain friendships as this gives them a feeling of well being and are subsequently content in the care they receive. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The care plans give clear guidance for the best way to support people so staff are assisting in a manner that meets individual needs. EVIDENCE: The care plans viewed as part of the case tracking process were seen to be comprehensive in providing clear guidance for staff on how to assist a person that best suits their needs. Other professionals that have been involved in people’s care include the chiropodist, physiotherapist, communication specialist and the Additional Support Team. All evidence confirmed that physical, emotional and health needs are met. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 15 Medication is stored in a metal cabinet as recommended during the previous inspection on 22/11/05. Medication practices were looked at and found to be in need of reviewing as the key to the medication cabinet was hanging above the cabinet itself and as such medication was not securely stored. Advice was given in relation to this recommending that the senior person on duty keep the key to ensure safe handling of medication. This was immediately acted upon. Records were up to date and accurate. Training should be given to those members of staff who have not yet had training in the safe handling of medications. A comment card received by the Commission for Social care Inspection from a relative states ‘I would like to highlight the excellent care Maria and her staff have provided this last year during my brother’s illness.’ Another relative stated, ‘My sister is very well cared for and treated as an adult, I have no concerns about her residential care.’ 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who live at Queens Terrace are protected from abuse by the policies and practices within the home. EVIDENCE: Neither the home nor the Commission for Social care Inspection have received any complaints since the last inspection on 22/11/05. The comment cards received from relatives reflected that they had no complaints but knew that if they had any issues that Maria (service provider) would listen and act to put it right. The manager has made sure that all service users and/or their relatives have had a copy of the complaints procedure, which is in the Statement of Purpose. The four people accommodated would probably not make a formal complaint, but staff are aware of behaviour changes and gestures that may indicate a person is not happy with something. There are opportunities on a daily basis for service users to make their wishes and opinions known. Staff are given guidance around “Awareness of abuse” through National Vocational Qualification (NVQ) in care and through Learning Disability Award 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 17 Framework (LDAF). This will go some way to ensure residents are protected from abuse. From discussion with a new member of staff it became apparent that there is no staff application form or formal interview although there was an informal discussion with the service provider. The addition of a staff application form would ensure people’s full employment history is known. The home ensures POVA first is completed for all staff prior to commencing work. The member of staff spoken with said she had filled in a Criminal record Bureau (CRB) clearance form but this was not back yet. The senior carer was aware that the new carer must work supervised until a clear CRB is received. The practice of ensuring 2 witness signatures for all financial transactions on behalf of the residents should be adopted, to safeguard the residents finances and protect the staff from wrongful accusations. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents’ benefit from living in a clean, comfortable and safe home. EVIDENCE: A tour of the home revealled that the home is well maintained and the residents individual bedrooms are full of their own possessions which reflect the individuals personality. They are decorated to the liking of the individual resident and as such are very different in appearance. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 19 None of the bedrooms have en-suite facilities, however there are two bathrooms situated on the first floor. There are two large lounges in the home, one of which is used for the use of the computer, while the second one is where service-users and staff watch the television. The home has a dining room and a kitchen/diner. The residents were seen to be free to wander around their home. All the rooms were bright and had a homely feel. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents’ benefit from having competent staff who receive training to carry out their roles. EVIDENCE: All staff usually have regular 1-1 supervisions, and a record of these is kept in the staff file, however over the last few months this has not occurred. The process of supervision provides opportunity to discuss training needs, competence, conduct etc. The owner of the home usually works on a daily basis and is very much “hands-on”. The new support worker stated that she had not had to complete an application form for her current role. Whilst she appeared very caring and patient it is necessary for all new staff to complete an application form in order 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 21 to gain written information about the individual, their background and potential suitability for the post. Written references are taken up and these were seen on the staff files viewed as part of this inspection. CRB (criminal Record Bureau) clearance is also requested, however the support worker on duty had not yet received her CRB but was working supervised at all times 3 Staff have achieved a National Vocational Qualification and 2 others are currently undergoing training. When the 2 successfully achieve this the home will have 50 of the staff qualified. A staff rota is displayed in the kitchen which shows the photograph of the person coming on duty and who is on sleep-in-duty, this excellent practice enables the residents to be clear about who is going to be caring for them. 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed and the residents live in a safe environment where their health and welfare is promoted. EVIDENCE: The service provider has made progress in some units in the Registered Manager’s Award since the last inspection. However due to bereavement she has not been able to complete this as yet. It was evident from the inspection that the service provider ensures that the home is run for the best interest of the residents and gives them every opportunity to air their views and 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 23 comments. She also ensures that the diverse needs of the residents are identified and met. The senior member of staff on duty stated that Maria would always ensure the residents are well looked after. The Inspector was provided with documentation in relation to maintaining a safe environment. This included records fire equipment testing and servicing as well as a current electrical installation safety certificate. The comment card received from relative stated ‘This is home from home’ 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 25 NO 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 YA20 Regulation 13(2) Requirement The key to the medication cabinet must not be left unattended. Timescale for action 02/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA32 YA35 Good Practice Recommendations New staff should complete LDAF, and 50 of staff should achieve NVQ level II in care. A training plan should be developed to make sure staff train in infection control, moving and handling, medication and health and safety. The registered provider should achieve the Registered Managers Award. Two signatures should be obtained for all financial transactions on behalf of residents wherever possible A staff application form must be developed for future applicants 3. 4. 5 YA37 YA23 YA34 12 Queens Terrace DS0000009984.V323521.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 12 Queens Terrace DS0000009984.V323521.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. 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