Inspection on 08/03/07 for 20 Queens Road

This inspection was carried out on 8th 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

20 Queens Road 23/06/08

20 Queens Road 03/01/08

20 Queens Road 29/09/05

20 Queens Road 17/05/05

20 Queens Road 22/12/04

20 Queens Road 03/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 20 Queens Road 20 Queens Road Bishopsworth Bristol BS13 8LB Lead Inspector Ashley Fawthrop Key Unannounced Inspection 8th March 2007 09:30 20 Queens Road DS0000020284.V326973.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 20 Queens Road DS0000020284.V326973.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. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 20 Queens Road Address 20 Queens Road Bishopsworth Bristol BS13 8LB 0117 9077224 0117 9699000 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) www.brandontrust.org The Brandon Trust Mr. Glyn Edward Massey Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Staffing Notice dated 02/10/1996 applies Manager must be a RN on parts 5 or 14 of the NMC register May accommodate 6 persons aged 45 years and over. Date of last inspection 29th September 2005 Brief Description of the Service: The Brandon Trust operates 20 Queens Road. The home is registered with the Commission for Social Care Inspection to provide personal care and nursing care to six people with a learning disability. The home provides registered nurse cover at all times. The home is situated in a busy residential area, close to major transport routes. There are local amenities including shops, social venues and a nearby public house. The home is a converted bungalow providing single rooms and communal space in two areas including an art/activity room for service user’s personal use. The home has a clear philosophy of care, which can be found in the statement of purpose. On the 8th March 2007 the charge for services were levied at £1,218.92. Additional charges are levied for extra social activities, hairdressing, music sessions and mini bus hire. These charges vary. Aromatherapy is £8.00 per session. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector within one day. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, the action plan submitted following the previous inspection, and reports from other agencies, i.e., the Fire Officer. This information was used to plan the inspection visit. The inspector case tracked four people using the service. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Pre inspection information was received before the visit was done and on the day of the inspection the staff were open and helpful throughout. The inspection included looking at records such as care plans and reviews of the care for people using the service and other related documents. The Inspector also read policies and procedures relating to the protection of vulnerable adults and health and safety. The views of the staff and people using the service were gathered either by face- to- face discussions or by surveys. What the service does well: Staff continue to encourage and support residents to continue with their chosen hobbies. One resident has her paintings and artwork on display around 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 6 the house and has been supported to participate in local art exhibitions. This resident showed the inspector her work and said ‘I love doing it, staff help me’. Other residents spoken with made various positive comments about the home and the support given, including, ‘my room is very nice’, ‘the staff are nice’ ‘staff take me shopping’ ‘ I’m happy’. The inspector enjoyed a homely comfortable atmosphere whilst inspecting and found residents relaxing, being offered support in a way in which suits them and making their choices known. 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. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 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 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2,4 and 5 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People wanting to use the service have access to good information before they move in and can make a decision on whether the home can meet their needs or not. people are given the opportunity to ‘test drive’ the home prior to moving in and individual needs and aspirations are assessed. Contracts are in place detailing the terms and conditions of the home. EVIDENCE: The Statement of Purpose and Service user Guide give any one wanting to use the service good information about the home and the services they can offer. The service users guide includes pictures as well written information. This is good practice as it makes the document easier to understand. On case tracking a number of care plans there was evidence that assessments are done by staff before the person moves into the home. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 9 This is good practice and gives the staff good information on the needs of the person so that the care plan can be started as soon as the person moves into the home. It was noted that assessments and care plans were in place completed by the relevant placing authority. I was informed that people wanting to use the service have the chance to visit the home before moving in and there was evidence that people have made a number of visits including over night stays. All the people that were case tracked had contracts and terms and conditions on their files. These also included pictures as well as the written word. 20 Queens Road DS0000020284.V326973.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. Residents care plans and risk assessments do not always reflect their assessed needs. Residents are consulted on aspects of running the home and are empowered to make everyday choices. EVIDENCE: I case tracked three peoples care plans and risk assessments. There was information describing peoples past experiences and gave staff good information on peoples life experiences and what is important to them. There was information relating to the physical, social and emotional needs of the person 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 11 It was noted at the last inspection that although the pre-assessments had been carried out the care plan did not relate to it. This has now been put right and the care plans were developed from the assessments done before the person moved into the home. Monthly updates were evident and the care plans were reviewed at regular intervals. The health and well being of people was seen as important and individuals had access to specialised treatment and had access to Nation Health services and facilities. On a number of care plans dates had been written when recording information this is not good practise as staff cannot see what is up to date and relevant to the persons immediate needs. Risk assessments in place relevant to individuals, these have been reviewed as required in the last inspection report these include all areas of daily living where there could be significant risk. Risk assessments are written when any special equipment is being used including bedrails and advice these are purpose made for the beds in use. people were observed being offered choices in areas of personal support, meal choices and activities. Meetings continue to be held and one staff member explained that input was gained from people who live at the home whose communication preference is non-verbal by means of observation. 20 Queens Road DS0000020284.V326973.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): 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. People living at the home have appropriate personal and family contact and are supported to maintain family links. People are a part of their local and wider community. EVIDENCE: There was evidence through case tracking that activities and socialisation play a big part of the life of people who live there. Visitors are encouraged to visit at any reasonable time and are made to feel welcome. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 13 There continues to be an in house policy available regarding respecting people’s rights. There was a confidentiality policy in place as well as a policy regarding choices made with personal care. There is evidence that people were encouraged to carry out their hobbies with support. Daytime activities have improved although since the last inspection. All of the people have a planned holiday and these are either on a one to one basis or where agreed by individuals in two’s. At the time of the inspection the inspection the kitchen and dining room was being replaced during this time people were eating out in restaurants or having take away meals. There was fresh fruit and cereals available as well as milk and bread. The refurbishment was due to be finished and the disruption was seen as minimal. 20 Queens Road DS0000020284.V326973.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. Staff provide sensitive and flexible personal support and nursing care to maximise people’s privacy, dignity and independence. Although medication policies and procedures are in place, these are not strictly adhered to, and a requirement has been made to ensure resident and staff safety. EVIDENCE: Case tracking showed evidence that people have access to specialist support where necessary and as recommended in the last inspection recommended ‘dementia voice’ was contacted to offer advice regarding the support of one person with a diagnosis of dementia. During discussions with staff they were able to demonstrate an understanding of the need to respect the person’s privacy and dignity. they were aware of gender issues and the areas of the service, which included the need to respect 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 15 people’s privacy. Residents’ were dressed in a style that reflects their personality. Times for getting up and going to bed are flexible and suit the individual. I looked at the medication systems there were policies and procedures available to staff. Medicines are stored in appropriate lockable cabinets and the administration and recording systems were safe. 20 Queens Road DS0000020284.V326973.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): 22 and 23 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who live at the home and their representatives are protected by the complaints procedure and the policies and procedures relating to the protection of vulnerable adults. EVIDENCE: There have been no complaints received by the Commission (CSCI) within this inspection year. There was a complaints book in place to record any complaints received from residents and staff. The complaints procedure is in a format that some of the of the people find accessible. Staff confirmed that they seek the views of the people at informal times of the day especially over a meal in the evening. Staff said they are aware of residents differing communication needs and are able to translate their wishes and feelings. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 17 Records continue to show that staff attend awareness of abuse training and the inspector suggests that this training become part of the annual rolling programme. 20 Queens Road DS0000020284.V326973.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): 24, 25, 27 and 30 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Shared spaces compliment people’s personal bedrooms. The home is suited to its stated purpose however requires some attention to ensure it remains comfortable and safe. EVIDENCE: The communal areas such as lounges and dining rooms were furnished to a good standard. At the time of the inspection a new kitchen was being fitted. I was invited into people’s bedrooms and found them to be personal and individualised. A tour of the environment was undertaken with the manager and it was noted that there were some areas requiring attention. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 19 Since the last inspection some work has been done to repaint areas that were flaking. There continues to be a problem with water damage in one room and the person in charge informed me that this was due to be investigated in the near future. There are adequate bathroom and toilet facilities to meet the needs of the resident group. However, there is one bathroom on the ground floor that requires redecorating as it looks institutionalised. The hallway carpet is also due to be replaced. 20 Queens Road DS0000020284.V326973.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): 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. There are appropriate staffing numbers and skill mix employed at the home to ensure the assessed needs of residents are met. Residents are protected by the homes recruitment policies although the documentation required by legislation is not kept on the premises. EVIDENCE: The staffing structure, numbers and skill mix employed at the home are appropriate for the number of people living at the home. One staff member said that she had undertaken training relevant to the needs of the residents as well as statutory training. She was aware of her job description and was able to describe her role and responsibilities within the home. She said ‘Supervision takes place 4-6 weekly’. The home manager confirmed this. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 21 There is a file that records personal identification documents of the staff members as well as personal and Criminal Records Bureau checks. Personal identification numbers for all of the qualified nurses are recorded alongside reference contacts. The documents themselves are stored a the Brandon Trust HQ and legislation currently requires all such documentation relating to staff employment to be kept on the premises. However, a local agreement has been made for these records to be held off the premises 20 Queens Road DS0000020284.V326973.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): 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. People living in the home benefit from a positive team with a sound management approach. People’s best interests are safeguarded by the Organisational policies and procedures. EVIDENCE: The fire logbook was examined and it was noted that all necessary checks of the fire alarm system and equipment takes place. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 23 The fire risk assessment was written in 2002 and would benefit from being updated. It is strongly recommended that the fire risk assessment be checked and agreed by the relevant fire specialist either through Brandon Trust or the Avon Fire Brigade. A member of staff said ‘I feel empowered and am able to make my own decisions. The management approach is good and we are all part of the team’. The manager said residents meetings take place every other month and these are more of a social get together than a formal meeting. Other staff members said that views were also sought from residents at bath times, and one to one times throughout the day. The home has a number of policies and procedures designed to protect and enhance the lives of the residents and staff team. 20 Queens Road DS0000020284.V326973.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 3 2 3 3 3 4 3 5 3 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 2 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 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 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation Requirement Timescale for action 01/06/07 15(2)BSchedule3(3)m Care plans must have all the information dated to make sure that staff are following the most up to date information. 23(2)(b) Walls in the quiet room to be investigated. The bathroom opposite the lounge is redecorated to make it more homely. 2. YA24 01/06/07 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 YA5 YA6 Good Practice Recommendations Where necessary make contracts accessible to residents. Contact dementia voice to seek support for one resident DS0000020284.V326973.R01.S.doc Version 5.2 Page 26 20 Queens Road with a diagnosis of dementia. 3. 4. 5. YA19 YA24 YA42 Put in place ‘quick view’ healthcare sheets. Replace the toilet frame with the drop down arm facility. The fire risk assessment to be checked and agreed by the relevant fire specialist either through Brandon Trust or Avon Fire Brigade. 20 Queens Road DS0000020284.V326973.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. 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