Inspection on 27/06/07 for Queen Alexandra Hospital Home

This inspection was carried out on 27th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Queen Alexandra Hospital Home 29/05/08

Queen Alexandra Hospital Home 23/01/06

Queen Alexandra Hospital Home 16/08/05

Queen Alexandra Hospital Home 06/01/05

Queen Alexandra Hospital Home 05/05/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Queen Alexandra Hospital Home Gifford House Boundary Road Worthing West Sussex BN11 4LJ Lead Inspector Val Sevier Unannounced Inspection 27th June 2007 10:30 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 Queen Alexandra Hospital Home DS0000024198.V344184.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 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. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Alexandra Hospital Home Address Gifford House Boundary Road Worthing West Sussex BN11 4LJ 01903 213458 01903 2194151 matron@qahh.org.uk 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 Hospital Home Limited Mrs Valerie Walker Care Home 60 Category(ies) of Physical disability (60), Physical disability over registration, with number 65 years of age (60) of places Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: Queen Alexandra Hospital Home is situated in a residential area of Worthing with local shops and other amenities within walking distance. The seafront and beach are close by. Residents living at the home are ex-servicemen or women and have chosen the home because of its connections with the armed forces. The home has recently completed a major new building project, which has increased the number of single bedrooms available at the home to 36 and provides a new occupational therapy, physiotherapy unit and further communal areas. A second phase of improvements is planned for the existing building to improve the accommodation and facilities at a later date. The fees for the home are per week and are based on assessed need and are banded on low £695, medium £795 and high needs £915. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 27th June 2007, during which the inspector was able to have discussions with staff and have interaction with the residents at the home. During the visit the inspector looked around the inside and outside of the home, which included a sample of bedrooms and bathrooms. Staff and care records were sampled and in addition to speaking with staff and residents, their day-to-day interaction was observed. The inspector has also received several surveys from people who use the service and relatives; some comments are included in the report. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. What the service does well: The home welcomes people who will use the service and their families or representatives, to visit the home and assess the facilities of the home. The manager actively seeks information from external healthcare professionals as part of the assessment where necessary, to ensure that the home is able to meet assessed needs. People moving into the home are assured that the home that they are entering will meet their needs. For example, staff are well trained and show perception and professionalism in the way they deliver care, which enables people who live at the home to feel safe and enjoy a varied and companionable way of life. Staff treat people who live at the home with respect; they share their companionship and give support sensitively. Detailed records were in place that gave nursing and care staff information that enabled them to provide the help that individuals need. Health care was promoted through the use of tools that assist with monitoring the nutritional needs of individuals when that was necessary. The home has also developed good working relationships with healthcare specialists. Daily routines in the home were flexible and people who use the service being encouraged to make choices for themselves and exercise personal autonomy as far as was reasonably possible. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 6 People who live at the home were positive about the food that the home provided and were pleased with the range of activities in which they could participate and the condition of the accommodation that they occupied. People at the home, relatives and staff had confidence in the effectiveness of the home’s manager. Systems and procedures in the home worked well including, dealing with complaints, quality monitoring, and health and safety. 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. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 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 Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are considering using the service are given appropriate information about the service to enable them to make an informed choice. People that use the service can feel assured that their needs will be assessed and that the home has an understanding of their needs using the assessment process. EVIDENCE: The service offers long or short stay rehabilitation and respite. The statement of purpose and service users guide is in the form of a brochure and contains information about the home and its facilities. For example: Residents Charter How to make comments complaints and suggestions Personal electrical appliances Data and information protection and access to health records Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 9 Fire safety Finding your way around Who’s who Daily routines and organised activities Service available to you and your family What you will need to bring with you on admission The guide also comments on the values of the home, on privacy, dignity, independence, civil rights, choice, fulfilment, ethnic and cultural diversity and security with statements such as: “…Offering a range of activities which enables each resident to express himself as a unique individual”. “Promoting possibilities for residents to establish and retain contacts beyond the home.” On initial enquiry of interest a package of information is sent out with an application form, the homes mission statement, the recent newsletter and a contact name and number. The application form asks for information about health and needs generally. An assessment visit is then arranged and carried out by either the registered manager or one of the nurse managers. After the assessment and when a decisions has been reached the assessment is given to the nurse manager of the area in which the person will move to, they then begin to develop the care plan and use it to assist with the admission to the home. The assessment includes the following areas: personal hygiene and dressing; safe environment; breathing; eating and drinking and swallowing; control of body temperature; working and leisure; sexuality; sleeping and aids to ability. Examples of the individual’s abilities within these areas were seen for example communication, “communication board or thumbs up”. It was also noted that there was information gathered from others who are involved in caring and supporting the individual, including the family and other health professionals. After the individual has moved to the home for a period of up to four weeks the home continues to asses the individuals needs and build the care plan, which us then reviewed after this assessment time. Comments from relatives include: ‘new contacts are issued when the charges change. The administration is very professional and thorough’. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The records and systems within the home that ensure that the personal and healthcare needs of people who use the service are met safely and effectively. However there was inconsistency in the management and recording of medication, which could place people who use the service at risk. Staff working practice helped to ensure that the privacy and dignity of people who use the service is promoted. EVIDENCE: The care plans sampled by the inspector were being used in conjunction with medication records and other health-monitoring tools that are used as part of the care planning for individuals. The care plans that have been developed for the residents were seen to be a working tool, with records of daily life and regular evaluations by the key worker. The documents examined and the plans were based on the assessments the home carried out in order to identify what help individuals needed. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 11 Assessments included a range of potential risks to residents e.g. pressure sores; falls; moving and handling; malnutrition; etc. Where a pressure sore assessment indicated that an individual was at risk it was noted that the corresponding plan of care for the person concerned referred to the use a pressure relieving aid. One of the nurses at the home has trained in tissues viability and supports her colleagues in the care of any areas at risk or that have broken down. The inspector was able to see that pressure are breakdown had been present when an individual moved to the home and there were no incidents of areas having developed by people who had been at the home for some time. It was also noted that the care and treatment in support of pressure areas that had broken down had been successful. The plans examined set out clearly the actions and support staff needed to take and what specialist equipment was needed to provide the support and assistance each person required. For example where support with movement was identified instructions on numbers of staff needed, equipment and communication was seen. Examples of instructions to staff included “if tired, can not easily make self understood, keep background noise to a minimum”. It was seen in the care plans that physical health needs are also addressed with recent residents having moved to the home with information from health and other specialists; this information has been incorporated into the care plan at this home. It was also seen that residents have access to opticians and dentists as needed. Notes regarding physical health indicated that other professionals had been involved as necessary for example the home has a speech therapist visit twice weekly to advise and support care for individuals who have difficulty on swallowing, eating, drinking and communication. Action was seen to be taken on this advice for example: one individual is waiting for a new wheelchair as their needs have changed, and is currently having meals in bed as this is the best way to ensure safety and being able to eat well. The individual is up and out of bed in between meal times. Comments included: ‘My relative is unable to speak and the carers always pay special attention to his needs and always make sure that he is smiling and happy’. It was also noted that individuals are seen as whole beings with needs and desires, no mattered their lack of ability in some life activities through illness, and to support this the home has also sought support from a sexuality therapist who has spoken with individuals and then guided the staff in how to support individuals. It was also seen that individual likes and preferences of self image had been recognised for example having their hair coloured and wearing make up and jewellery. It was seen that individuals have been assessed regarding risks in their dally lives, and that support had been put in place to minimise the risk for the individual whilst also enabling them to participate in the activity, for example Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 12 people who use a wheelchair independently may be at risk of falling out have straps and belts to support them. Records indicated that care plans were reviewed regularly and as needs changed and daily notes referred to the actions taken by staff to provide the needs set out in those plans. Care plans are agreed with the person using the service where possible and their relative or representative. The home had written policies and procedures concerned with the management and administration of medication. Medication was kept in locked and secured medicine trolleys, cupboards and where required in a medical refrigerator. Controlled drugs were stored securely and appropriately. The home dispenses all medication from blister packs and the only staff in the home that dispensed and were responsible for the management and administration of medication on a day-to-day basis were registered nurses. There was evidence that people who use the service are enabled to continue with their own medication and this is assessed and reviewed as needed. The records and stock were sampled and it was noted that there were 35 gaps in the administration records were it could not be seen if medication had been given, this includes ten for one item (see below). The records seen had been started on the 24th June the week of the inspection. Several post it notes had been stuck onto the administration sheets, these were bought to the attention of the manager, as these notes may not have been on the right record, they were not dated or signed. It was seen that for one individual Prednisilone 5mg had been written by hand on the administration record, there was no indication on when or how often this should be given, although it was being given in the morning. Another individual had been prescribed Daktacort cream to be applied twice a day, it was unclear when this cream had been prescribed although the first signature was 16th June 2007, between then and the day of the inspection 27th June 2007 there were ten gaps where no record was made as to whether the cream had been applied. Staff were observed speaking and assisting the residents with dignity and respect. Affection was given appropriately to those residents who sought it. It had been seen on care plans that the preferred choice of name had been recorded and staff were heard to speak to residents by the name they wished. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 & 15 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service participate in activities appropriate to their age, peer group and cultural beliefs as part of the local community. Dietary needs are well catered for with a balance and varied selection of food available that meets individual dietary requirements and choices. EVIDENCE: The people who live or stay at the home are all ex service me or women and this may have been something that influenced their choice to move there. Activities are available for individuals in the physiotherapy area where there are trained staff and equipment available to encourage and maintain mobility and skills. There are also activities in the occupational therapy area, which also includes a kitchen with adjustable work surfaces and a computer room. A programme was seen for June which included: crafts, crosswords, dominoes, darts practice – the people at the home have a team which competes outside of the home, skittles, two cooking days – cakes and full lunch and indoor bowls. In addition there are trips out Founders day at Chelsea hospital, London Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 14 Tax drivers tea and show, Leeds castle as well as the home having an open day on the 30th June. Papers are available for all to use from Monday to Saturday and individuals are enabled to have heir own papers and magazines delivered. There is a library area, which has its books refreshed regularly. There is a public pay phone, which people who use the service can use to make or receive calls and individuals can have a phone in their room that is billed directly to them. Comments included: ‘The occupational therapy department keeps the residents who want to very busy with a variety of activities from cooking to darts to dominoes; there are least two outings a months which are well run’. All residents spoken who were able to pass comment were complimentary about the food provided. The meals seen looked nice and were presented in a way that looked appealing and could assist an individual with sight impairment, to eat independently with support for example, the meals were divided into sections at 12, 3, 6 and 9, so staff could tell the individual what and how the meal was presented and the individual could then choose where and what they ate. The menus and records of food provided indicated that the food was nutritious and there was a wide range of meals provided with a selection of choices every day. In addition special diets and individual preferences and needs were catered for e.g. soft and pureed meals and diabetics. Residents could choose where to eat and some preferred to eat in their rooms. Food preferences, dislikes, food related allergies and nutritional and dietary requirements were recorded in residents care plans and the information was also readily available to catering staff. The head cook explained that since taking over the kitchen he had moved towards healthy eating with low fat foods, no processed foods and more home cooking. The main meal of the day was observed and it was unhurried and staff were sensitive when providing assistance. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are protected through the open complaints process and the staff’s knowledge and understanding of Adult protection issues. EVIDENCE: The homes complaints procedure was seen to be available in the information given to people who use the service. There have been no complaints received by the home or the commission since the inspection visit in 2005. The manager advised that the home promotes an open door approach to relatives and people who use the service, to help resolve complaints and issues effectively. The home uses West Sussex safeguarding adult policy and staff were seen to have training in adult protection as part of their induction as well as yearly updates. The manager considers this to be a mandatory training area for staff. On the day of the inspection the manager advised that a referral had been made to socials services about an issues that was felt to be affecting the safety of an individual at the service. It was noted that staff had felt concerned and Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 16 had reported using the appropriate policy and methods. An email was seen that social services were to investigate the concern raised. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have a pleasant and homely environment to live in which also has had adaptations to meet individual needs. EVIDENCE: The inspector looked around some of the home and was able to see communal areas such as the dining room, the bar, kitchen, quiet area, bedrooms, bathrooms, occupational therapy area and physiotherapy area. There are several garden areas and a terrace and balcony for people to use, accessible with wheelchairs. All of the bedrooms seen were brightly decorated and had evidence of individual personalities with posters and the service users photographs on the walls, and other personal effects. People who live at the home are encouraged to furnish the room with personal belongings such as Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 18 furniture and pictures, to make it feel like home. Consideration is given to the support of needs with the use of equipment. Specialist beds are available at the home for those that are assessed as needing them. There is also specialist seating, a lift and adapted bathing facilities. There are rooms with ceiling hoists systems and areas for charging wheelchairs. It was noted that in accordance with best practice all communal WCs that were seen were provided with liquid soap dispensers (that were full and working), alcohol gel sanitizers and paper towels. Protective clothing was readily available and staff were observed using gloves and aprons appropriately. The home’s laundry was appropriately sited and equipped and effective procedures were in place for the management of soiled laundry items. The home manages all the laundry with dedicated staff. There was no was no malodour in the home and it was seen to be clean and tidy. Comments from residents about the condition of the premises included: • “They are particular about keeping it clean, the windows ands so on, I think they also look after the building”. • “It is kept spotless and I like looking out of the window. The trees and plants change colours and I can see the birds”. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services have their needs met by staff who are trained, supportive and sufficient in numbers. People who use the services are potentially at risk because of the current recruitment procedure. EVIDENCE: The staffing structure provides a broad spread of experience and professionalism: manager, nurses, support workers, physiotherapists, occupational therapists, speech therapist, kitchen staff, laundry and housekeeping. Other health care professionals support the team from outside the home as needed. Staff spoken with on the day of inspection indicated that they were aware of the needs of the residents who live at the home; they also seemed enthusiastic about working at the home. The rotas indicated that there were sufficient staff to meet the needs of the people at the home. There was evidence that staff have received training in all mandatory areas such as food hygiene, first aid and manual handling, health and safety, vulnerable adults, infection control, continence management and challenging behaviour. The registered nurses maintain their training through in-house and external courses. Staff receive at last three days training a year and are enabled to access courses either at the home or externally for example tracheotomy and mentorship training. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 20 The responsible individual has undertaken an external course in health and safety and is qualified to teach it at the home, the registered manager has recently completed a course in challenging behaviour and has started to deliver this to staff in small groups and has added it to the mandatory training undertaken by all staff. In addition ten staff have also attended a days course on this issue. The occupational therapist has completed a training course on cognitive impairment to assist with supporting people at the home and staff. There are currently two student nurses at the home who are working with the navy and army respectively. One commented that they have found the placement at the home valuable and felt supported by their mentor. New staff undertake two-day induction period when mandatory training is undertaken. This is followed by the induction pack, which is supervised by the individual staff members mentor. The time taken to complete this induction pack, which is based on ‘Skills for Life’, depends on the individual member of staff. Modules covered are: layout of the home, security including identity badges and safety of residents belongings, heath and safety for example fire and incidents, communication for example call bells and methods of communication, procedures, staffing and working with others. Staff are seen monthly whilst undertaking the induction pack, after this period it is every two months. Staff also have a yearly appraisal when training and development needs are looked at for the coming year. Records were examined of four staff that had been employed to work in the home since the last fieldwork visit to the home. Records indicated that statutorily required pre-employment checks, intended to ensure that people unsuitable to work with vulnerable adults were not employed, had been completed before the individuals concerned actually started working in the home. However, it was noted that there was no separate POVA First check undertaken before employment began. The inspector asked the human resources manager how employment commenced, as it was noted that a Criminal Records Bureau check (CRB) had been undertaken for all staff files seen. The manager explained that after interviewing, references are sent for and the CRB check is requested, a member of staff commences employment after the references are received and under supervision whilst waiting for the CRB check to be completed. The POVA First is included on this check but is not completed before employment commences. The inspector bought to the attention of the resources manager, registered manager and responsible individual that this is not acceptable practice. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. With the exception of the medication and POVA First checks, people who use the service benefit from a well run home; with systems and procedures in place which monitor and maintain the quality of the service provided and promotes the safety and welfare of everyone living and working in the home. EVIDENCE: Valerie Walker the registered manager has been at the home for seven years, she is a registered nurse and has many years experience working with individuals with acquired brain injury. Both the manager and responsible individual have undertaken the Registered Managers Award. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 22 With the exception of the medication and POVA First checks the home appears to be run well with good systems, communication and management. There were a range of written policies and procedures available for staff to refer to as guidance and to inform their practice. These included the following: • Admission, discharge and transfer of residents • Human Rights • Confidentiality and access to personal records • Abuse of the person • Drug administration • Self administration of medication • Infection control • Complaints procedure • Whistle-blowing • Sexuality • Health and safety at work The people who use the service and their relatives or representatives and the staff, are able to discus all aspects of the running of the home generally or on a personal level. This opportunity is offered in resident, relative and staff meetings, and in questionnaires. A recommendation regarding personal monies was made following the last inspection visit to the home. The inspector asked whether this had been acted upon. The home has a finances manager who assists with the management of monies of people who are unable or no longer wish to manage their monies, The registered manager and responsible individual are power of attorney for several individuals who live at the home. Following the last inspection the home investigated separate accounts for all individuals it was felt that this was not manageable. The home has however set a limit of money that is kept and once this limit is reached, the money is moved to a high interest account. All monies held on behalf of people who live at the home are logged into an individual account with records kept. Where possible people who live at the home are encouraged to take care of their own money. It was noted that the home’s equipment, plant and systems were checked and serviced or implemented at appropriate intervals i.e. passenger lift and hoists; fire safety equipment portable electrical equipment; hot water system; etc. There were contracts in place for the disposal of clinical and household waste. Records were kept of accidents. There was a fire risk assessment for the premises; tests of equipment and regular risk assessments of the premises and working practices were undertaken regularly. Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 23 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 3 X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X 3 X X 4 Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 (2) Requirement To protect people who use the service, medication administration records must be maintained in accordance with the homes policy and Royal Pharmaceutical Guidelines, and Post it notes which promote unsafe practice must not be used. POVA First checks must be carried out before staff commence employment to protect the people who use the service. Timescale for action 25/07/07 2 OP29 19 Sch 2 25/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen Alexandra Hospital Home DS0000024198.V344184.R01.S.doc Version 5.2 Page 26 - 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!