Inspection on 24/01/06 for Qu`Appelle

This inspection was carried out on 24th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Qu`Appelle 04/07/06

Qu`Appelle 11/08/05

Qu`Appelle 19/01/05

Qu`Appelle 30/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Qu`Appelle 32 West Street Bourne Lincs PE10 9NE Lead Inspector Julie Western Unannounced Inspection 24th January 2006 09:30 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 Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 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. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Qu`Appelle Address 32 West Street Bourne Lincs PE10 9NE 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) 01778 422932 Qu`Appelle Residential Care Home Ltd. Care Home 19 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (15) of places Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Condition of Registration During the first year of trading, the company is required to employ the services of a suitably experienced person on a consultancy basis to advise on the requirements of the Care Standards Act 2000. Condition of Registration Mr Sunnar is required to undertake training on the protection of vulnerable adults within the first six months of registration. Condition of Registration Mr Sunnar is required to undertake training on recruitment, selection and employment law. Condition of Registration Mr Sunnar is required to undertake training regarding the Health and Safety at Work Act 1974, within the first six months of registration. 11th August 2005 2. 3. 4. Date of last inspection Brief Description of the Service: QuAppelle is a two storey period house with an adjoining cottage. It is situated within a block of other period houses and is within 500 metres of the centre of the town of Bourne, with its shops and local amenities. The home is registered to provide personal care for up to nineteen people of both sexes over the age of 65 years, four of whom have a diagnosis of dementia. There are eleven single and four double bedrooms, none of which is en-suite. Communally, there are two lounges, a sun lounge and a dining room on the ground floor. Access to the first floor is via a stair lift. There are three communal bathrooms and seven toilets on the two floors. A garden is available to residents at the rear of the property. Limited car parking is available on the road outside the home and on roads near to the home. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours. A partial tour of the building took place and care records were inspected. Some policies and procedures were examined and records concerning the safety of the home were also seen. The main method of inspection used is called case tracking; this involves selecting a proportion of residents and tracking the care they receive through the checking of records, discussion with them, the care staff and observation of care practices. The inspector spoke with three residents, three visitors, three healthcare professionals and two staff members. The owner of the home and the Manager, who is currently unregistered, were present throughout the inspection. What the service does well: What has improved since the last inspection? All staff members have been trained in the safe handling of medicines. Quality assurance questionnaires have been developed for residents and relatives. The Manager has started to clear out the office and to revise policies and procedures. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 6 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. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 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 Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The statement of purpose does not demonstrate what the home intends to do for its residents. The service user guide ensures that information is freely available to residents, but could be in more simple language. A comprehensive initial assessment ensures that the needs of residents can be met. Prospective residents are encouraged to take time before making the decision to move into the home on a permanent basis. EVIDENCE: The statement of purpose is not in a suitable format and is not in enough depth. The service user guide has been updated to include the information required to enable prospective residents to decide whether the home is suitable for them, but would benefit from being easier for residents to read. The terms and conditions contract is comprehensive. Pre-admission assessments were in the care plans examined and formed the basis of those care plans, showing involvement of the prospective residents and their relatives. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 The home’s records give a clear indication of the needs of residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity. EVIDENCE: The three care plans looked at in depth contained clear and comprehensive assessments, were reviewed regularly and were signed where possible by the service user or relatives/advocates. There was a clear medication policy and the pharmacist visited regularly, the last visit being 29/6/05 and from which there were no issues. It was recommended that a drugs trolley was purchased and the fridge moved into the office so that all medication was dispensed from the same area. Residents said they felt safe and well looked after; one said ‘They’re very kind’ and another said ‘I can’t fault it’. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Social activities are extensive and well promoted, creating a variety of events and activities which residents are informed about. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat; the menu needs reviewing to include alternatives at lunch times. EVIDENCE: The home has an activities co-ordinator who works 6 hours weekly and a carer who works 2 hours weekly. The home has a designated member of staff responsible for the co-ordination of activities and she devotes one day per week to this. Residents and visitors spoken with said that recent activities had included a Christmas party and residents who wished to, had made their own Christmas cards. All residents received sherry and presents on Christmas day. Regular activities included various entertainers, church visits, excercises and Bingo. All residents said they enjoyed the food; one said ‘It’s good – there’s a three course lunch’. The kitchen staff demonstrated a knowledge and awareness of special diets. Menus were currently being reviewed and showed that there was a balanced and varied diet, but they did not show an alternative to the main meal. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; the adult protection procedure needs updating. EVIDENCE: Residents and visitors to the home all said they did not wish to complain but knew how to make a complaint. The home had received one complaint in the last twelve months; this had been responded to appropriately and within the given time. A suggestions box was located in the front entrance hall. The adult protection procedure was not linked to the Local Authority procedures, which were out of date. All staff members spoken with had received training on adult abuse and were knowledgeable about complaints. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 26 The residents live in a comfortable, pleasant and safe environment with both private and communal space being on the whole suitable for their needs. EVIDENCE: Overall, the standard of decoration internally was high and afforded residents a great degree of comfort. Rooms were clean, comfortable and well personalised. The gardens were well tended, with places for residents to sit out in good weather. Residents, visitors and health care professionals said that the home was clean and tidy and always smelled fresh. One relative said that the home was so homely and comfortable that her relative didn’t realise she was in a home. The owner said that the temperature of hot water at the sink outlets was high again due to a sticking valve and that the plumber was visiting this week. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected. EVIDENCE: Although these standards were not fully inspected, the staff rota showed that staff numbers were in excess of the staffing matrix and shifts were staggered to accommodate the needs of residents; residents and staff thought there were enough staff members on duty to complete their tasks. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 38 The home is managed competently and the staff are supported in carrying out their respective roles. Residents are included in decisions affecting them. EVIDENCE: The manager, who is currently unregistered, is an enrolled nurse who has worked in various roles in the care sector and has a Teacher’s Award. She is working towards her NVQ 4 in care, to be followed by her Registered Manager’s Award and will apply within the next few months to become the registered manager. Residents and visitors as well as staff commented that the manager was approachable and accessible. A quality assurance system has recently been put in place, with questionnaires being sent to residents, relatives and staff members. Policies and procedures are currently maintained in a haphazard fashion and the Manager said that she was in the process of re-organising the office and the paperwork. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 15 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 3 X X X 3 X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 2 X Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? yes 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 OP1 Regulation 4[1] Schedule 1 16[2](i) 13(4) Requirement Timescale for action 23/03/06 2. 3. OP18 OP25 4. OP37 17[3] The registered person must complete the statement of purpose and forward a copy to the CSCI on completion. The registered person must 23/03/06 ensure that menus contain an alternative to the main meal. The registered person must 23/03/06 ensure that the hot water temperatures in the wash hand basins in their bedrooms are safe. This is a recurring incident due to a sticking valve; the plumber has been called to rectify the situation The registered person must 23/03/06 ensure that the home’s records are up to date and in good order. Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 17 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 OP1 OP9 Good Practice Recommendations It is a recommendation that the service user guide is in a format suitable to the requirements of the service users, eg. in a bold print and easy to understand.. It is a recommendation that a drugs trolley is purchased and chained to the office wall and the fridge is moved into the office so that all medication is dispensed from the same area Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Qu`Appelle DS0000052676.V279840.R01.S.doc Version 5.1 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. 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!