Inspection on 30/11/05 for Queen Alexandra College

This inspection was carried out on 30th 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queen Alexandra College 15/10/08

Queen Alexandra College 27/02/07

Queen Alexandra College 21/03/06

Queen Alexandra College 06/10/04

Queen Alexandra College 26/05/04

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

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Polesworth Group 70 Long Street

Breme

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

CARE HOME ADULTS 18-65 Queen Alexandra 49 Court Oak Road Harborne Birmingham West Midlands B17 9TG Lead Inspector Claudette Morgan Unannounced Inspection 11.30 30th November 2005 and 2 December 2005 nd Queen Alexandra DS0000016808.V269636.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 Queen Alexandra DS0000016808.V269636.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. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Queen Alexandra Address 49 Court Oak Road Harborne Birmingham West Midlands B17 9TG 0121 428 5050 0121 428 5048 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) Queen Alexandra College Mr Michael Gray Care Home 40 Category(ies) of Learning disability (40), Sensory impairment registration, with number (40) of places Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 6th October 2004 Brief Description of the Service: Queen Alexandra college is a facility that specialises in meeting the needs of people with visual impairment and associated learning and physical disabilities. The inspection report is in relation to the registered residential accommodation comprising of four homes, three on the college campus and one a short walking distance away on Lordswood Road, Harborne. The college has a number of other houses both on the campus and in the local community that are not registered but are providing supported living or are unstaffed. The college is located in Harborne, Birmingham. Access to public transport is good and there are a variety of shops, restaurants, pubs, library and other facilities close by. The registered houses are as follows; Thornton House: This house is made up of two units namely Hambland and TSB, (named after Trustee Saving Bank following a donation). Each unit is self-contained and are situated on the college campus. TSB, had ten bedrooms, two communal lounges, kitchen and a laundry. There is also an assessment room for prospective students. Hambland House has nine bedrooms, a communal lounge, kitchen, staff office and sleep in room. Winfield House: It is situated away from the main college campus, on the Lordswood Road. It has twelve bedrooms, two lounges, separate laundry and kitchen with a dining area. Winfield is geared towards the more independent students. Students who live at this house learn a mobility route from the college to the house, which they will access independently. In the summer of 2000 Winfield House was extensively refurbished. On the ground floor there is an office, a large lounge, large kitchen, dining room, laundry, smokers lounge, toilet facilities and three bedrooms. On the first floor there are a further nine bedrooms, staff sleeping in room, bathrooms, shower rooms and toilets, and a small kitchenette. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 5 Woodville House Woodville House is situated within the college campus there are eight bedrooms and a separate self-contained flat to enable the opportunity for one student to live more Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 30th November 2005 and 2nd December 2005. The inspector looked at records, policies and procedures, interviewed the manager, and had discussions with staff and students. The inspector was also able to tour the relevant homes. The staff and students fully cooperated with the inspection. What the service does well: What has improved since the last inspection? There is a new computer system in place that enables the homes to store essential information on the students. There are copies of pre-admission assessments in the homes. The quality of recording in the student’s daily records has improved. There is more detailed recording of complaints. All homes have copies of anti-bullying policies. Some outstanding repairs to TSB have been completed. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 7 The home’s policies have been reviewed at updated. 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. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 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 Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5 All the arrangements for pre and post assessments ensure students are consulted and their needs are met. EVIDENCE: The inspector was able to observe evidence on files that pre admission assessments had taken place for the students based in the homes. Prior to admission the student’s needs were fully assessed to ensure there were sufficient resources to meet them. The manager takes an active part in the assessments. All prospective students had the opportunity to visit and stay at the home prior to admission. There was evidence that the student’s parent or significant person is also able to stay on the college grounds during the pre-assessment period. There are also occasions that the manager will undertake home visits to assist with the assessment process of more complex cases. The records looked at by the inspector confirmed that there were signed agreements between the students and the college. The students interviewed by the inspector confirmed that they were aware of their agreement and felt they had been fully consulted regarding the contents of it. The inspector’s observation of interaction between staff and students demonstrated that both parties had clear expectations of each other. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Students are encouraged to contribute to decisions that affect their care in the home and their future. Guidance is provided to enable students to take controlled risks. These arrangements ensure that the student’s needs are fully met. EVIDENCE: All students have an action plan that sets out the various aspects of their care such as, independence training, diet, health, education, employment, contact, behaviour and leisure. The student and where appropriate family play an active part in the contents of the plan. The inspector looked at records that demonstrated that the plans were monitored regularly and individual achievable targets were set for the student. The students were fully aware of the contents of their action plans. The home is very proactive in encouraging students in the relevant decision making and ensured they were provided with the relevant information to make informed choices. The inspector observed staff advising a young person about the dangers of alcohol in his particular circumstances whist recognising his right to go out socially. There is regular planned consultation between staff Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 11 and students and evidence that students were able to approach staff at other times they had a concern. There was evidence of detailed risk assessments and others that contained sufficient information for the specific task being carried out. The manager informed the inspector that there were plans to develop consistency in the risk assessments used in the homes. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Students are supported and encouraged to integrate in the community and maintain relationships with family and friends. Leisure activities are promoted and their rights are respected. EVIDENCE: All students attend the college full time and were able to undertake various further education courses that would assist them in their future career choices. The students told the inspector of individual subjects that they enjoyed. Students are able to participate in a range of activities that are provided at the provided by the college and the individual homes during the evenings and weekends. The college has an established relationship with the local community. There was evidence that the local community are encouraged to use resources at the college such as their leisure facilities and bike repair service. Some students informed the inspector that they regularly used the local community resources for activities and shopping. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 13 The inspector observed staff organisation of structured activities for students. At the time of the inspection some students were going on a swimming trip. There was also evidence that students were able to participate in a variety of in house activities that included, board games, music, TV, videos and computer games. There were some students that were able to organise their own activities in line with their independence training. The students were able to maintain regular contact with their families by telephone and visits. All students returned home at the end of term and some students also returned home at weekends. The inspector observed that students were able to receive visits from their friends. All students had their own bedrooms and access to communal areas. There was evidence that the students were able to exercise a level of independence in line with their action plan, age and ability. The inspector observed that staff knocked on the student’s bedroom door and waited for a response before entering. The students told the inspector that their privacy was respected by staff. Some students said that they did not like the evening meals prepared in the college and preferred to make their meals in the homes. The inspector observed that the homes had a variety of food to prepare meals and snacks. The main meals were provided in the college canteen and offered a range of choices. One student informed the inspector that he did not feel there was sufficient choice of meals and was not always happy with the quality of evening meals provided. The majority of students informed the inspector that they were satisfied with the meals offered. There were copies of menus and records of meals consumed by students. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Students live in an environment where their health care is fully promoted and are provided with appropriate guidance to maintain their personal care. EVIDENCE: At the time of the inspection there were no students that required assistance with personal care. The college’s pre admission assessment process is used to determine suitability of the student and their level of dependency. Some students did require supervision and prompt regarding their personal care. The staff demonstrated sensitivity in this area. All students had access to a bath/shower room that they were able to use in private. The records sampled confirmed that students had health care plans that were linked to their action plans. There was evidence that students health and well being was promoted by staff. The students were registered with a GP and had access to the college nurse. The college also had links with other health professionals that were required to meet specific medical needs of the individual students. Examination of student’s medical records confirmed that medication administration records were completed appropriately for students on medication. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 15 The team leaders at the various homes informed the inspector that there had been difficulties receiving medication on time from the chemist they used to provide medication and medication administration recording system. Plans had commenced to use an alternative chemist. There were clear policies in place for the use of prescribed and non prescribed medication. Some students are able to self medicate following a risk assessment. All medication is stored in a lockable cabinet. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Students live in homes where their views and concerns are heard. There are policies in place to protect students from abuse. EVIDENCE: There are various systems in place for students to raise their views and concerns such as, student meetings, key work sessions, meetings with the manager and the homes complaints procedure. The inspector observed students openly express their views to staff. The majority of students felt that they were listened to by staff. One student informed the inspector that he did not feel his concerns were taken seriously but the manager confirmed that all complaints were fully investigated and the records sampled supported this. The home has adult protection and anti-bullying policies that is known to staff and students. The students informed the inspector that they felt able to approach staff with concerns of bullying. The records looked at confirmed that bullying was not tolerated at the homes. There was a system in place for the safe keeping of student’s money and the records had been completed appropriately. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 17 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): 24, 30 The homes provided for students to reside are clean, hygienic and homely. EVIDENCE: The homes presented as homely and welcoming. The students and staff had placed Christmas decorations around the homes. Each student had their own bedroom that they were able to personalise. There had been some redecoration in Hambland. All outstanding repairs had been reported and in the process of repair such as shower area in TSB. Internal fire safety checks were carried out within the required timescales. At the time of the inspection all the houses were found to be clean and well presented. There were laundry facilities in all the homes that were accessible to the students. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 18 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, 34, 35 Students are cared for by staff that have the appropriate training and supervision to ensure their needs are met. EVIDENCE: The staff were observed to be very motivated in their work with students. The manager has appropriate management qualifications and provides supervision for the deputy manager and team leaders. All staff receive guidance support and appropriate in house and external training to equip them to undertake their role. The staff demonstrated awareness of the complex needs of the students. Relationships between staff and students are based on respect. The staff files sampled confirmed that all the relevant vetting checks of references, CRB and proof of identity were carried out. The records sampled and discussions with staff confirmed that staff received an induction period. The inspector saw evidence of a planned training programme for staff that covered, foundation and induction training week, food and hygiene, fire safety and other relevant training to meet the specific needs of the students. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 19 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, 42, 43 Students live in homes that are managed by competent staff that have appropriate training to maintain their safety. EVIDENCE: The Registered Manager has the appropriate management qualification and extensive experience and knowledge of the client group based at the college. He is highly motivated and committed to the ongoing development and advancement of the college and residential houses. There was evidence that the fire safety checks had been completed in each home. Full details of regulatory, gas, electric and servicing of lifting equipment were not available in the homes as they were held in the maintenance department. All accidents were recorded appropriately. There were satisfactory risk assessments for the homes and evidence that staff had received relevant induction training that included areas of health and safety. At the time of the inspection regulation 26 visits were below the required frequency. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 20 The manager informed the inspector that this was being addressed. Management tasks are shared between the manager and the deputy. The inspector observed that manager was unable to fully access information held by the deputy in the deputy’s absence. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 21 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 3 X 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Queen Alexandra Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 2 DS0000016808.V269636.R01.S.doc Version 5.0 Page 22 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 YA9 Regulation 13(4) Timescale for action A consistent approach must be in 14/02/06 place for student risk assessments and contain the relevant information for specific tasks. An alternative provider of 31/01/06 medication must be in place to ensure efficiency in Medication Administration Recording system All visits under regulation 26 28/02/06 must be carried out within the required timescales. Requirement 2 YA20 13(2) 3 YA43 12(1) 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 YA42 YA43 Good Practice Recommendations Consideration should be given to the homes having copies of regulatory safety checks. The manager must devise a system that enables access to relevant management information in the absence of the deputy. Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Queen Alexandra DS0000016808.V269636.R01.S.doc Version 5.0 Page 24 - 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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