Inspection on 22/11/05 for 12 Queens Terrace

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

12 Queens Terrace 13/09/07

12 Queens Terrace 02/03/07

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 Ms Janet Spink Unannounced Inspection 10:00 22nd and 23 November 2005 rd 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 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.V251949.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 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.V251949.R01.S.doc Version 5.0 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 Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 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. 1st July 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 of both sexes. 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 proerty there is a large garden. 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over two days for a total of four and a half hours. The inspection included case tracking a resident, observation of staff interaction with residents, discussions with the manager and staff, and viewing documentation. What the service does well: What has improved since the last inspection? What they could do better: The storage of medication would be better in a metal cabinet in place of the present wooden one currently used. Staff who had not received training in safe medication practices should do so. Training should continue to be improved to ensure the staff have the necessary skills and knowledge to support the four service users. A training and development plan should be produced in relation to moving and handling, infection control, first aid and food hygiene. The recent progress of some staff working towards a relevant care qualification should continue to make sure that half of the staff team gain this award. 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 6 The homeowner should continue working towards completing the Registered Managers Award. 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. 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 7 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.V251949.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed. EVIDENCE: 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 The homeowner 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: There have been no changes regarding care plans 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. Risk assessments are in place to make sure people are safe, and these address areas such as chopping food, using taxis and using stairs. 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed. EVIDENCE: 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The care plans give clear guidance for the best way to support people so staff are assisting in a manner that meets individual needs. The medication policy needs reviewing and shared with staff so that they are aware of current procedures in the home. EVIDENCE: The care plans 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. Medication practices were looked at and found to be within a safe framework, but could be improved by the provision of a metal cabinet instead of the wooden one presently being used. 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. 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home ensures that service users are aware of their rights and has a complaints procedure. Systems are in place to reduce the risk of abuse. EVIDENCE: 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, as well as the more formal reviews. Staff are given some guidance around “Awareness of abuse” through National Vocational Qualification (NVQ) in care and through Learning Disability Award Framework (LDAF). This will go some way to ensure residents are protected from abuse. 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed. EVIDENCE: 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 35 Training has improved to ensure that staff have the appropriate skills and knowledge to meet the needs of residents. EVIDENCE: Two members of staff are currently doing NVQ level III in care and have made some progress towards achieving this award. A recently appointed member of staff is doing the LDAF in order to gain underpinning knowledge of the needs of people who have a learning disability before she commences the NVQ award. Staff were receiving training in “Inclusive communication” (level II) on the first day of the inspection, and the Additional Support Team have been involved in providing training in behavioural management. A training plan should be developed to make sure that all staff have the core training for infection control, moving and handling, food hygiene and health and safety. All staff have regular 1-1 supervisions, and a record of these is kept in the staff file. This provides opportunity to discuss training needs, competence, conduct etc. The owner of the home also works on a daily basis and is very much “hands-on” and is therefore able to offer supervision daily. 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home is well managed and run in the best interests of the service users. There is good leadership, guidance and direction to ensure that they receive consistent care. The home is well maintained to ensure the safety of service users and staff. EVIDENCE: The owner has made progress in some units in the Registered Manager’s Award since the last inspection. It was evident from the inspection that the manager ensures that the home is run for the best interest of the residents and gives them every opportunity to air their views and comments. 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. . 12 Queens Terrace DS0000009984.V251949.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 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 2 x x 2 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 12 Queens Terrace Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 3 x DS0000009984.V251949.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action 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 3 4 Refer to Standard YA32 YA35 YA37 YA20 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. A metal cabinet should be used to store medication in place of the existing wooden one. 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 12 Queens Terrace DS0000009984.V251949.R01.S.doc Version 5.0 Page 19 - 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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