CARE HOME ADULTS 18-65
Queen Ann Lodge 36 Old Park Road London N13 4RE Lead Inspector
Tony Brennan Key Unannounced Inspection 21st June 2007 11:00 Queen Ann Lodge DS0000010703.V337123.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 Queen Ann Lodge DS0000010703.V337123.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. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Queen Ann Lodge Address 36 Old Park Road London N13 4RE 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) 020 8882 2336 Mrs K B Kelly Ms Pamela Kelly Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The number of service users that the home is able to accommodate is seven adults of either gender. Any resident accommodated in the second floor bedroom has no mobility impairment, including sensory impairment and does not require assistance in the event of evacuation of fire. The registered manager provides a copy of the registration certificate and these conditions to the London Fire & Emergency Planning Authority. The change in useable space in the first floor front bedroom is noted as being acceptable. 27th February 2006 Date of last inspection Brief Description of the Service: Queen Ann Lodge is registered to provide personal care for seven service users who have mental health problems. The home has been operating for almost two years and the proprietor also owns the premises next door, which is also a registered care home. The home has been well adapted for use as a care home. All service users have single rooms, some of which are very large, these are located on the ground and first floors. There is a recently added bedroom on the second floor that has en-suite facilities. There are also well kept communal areas and a well maintained garden to the rear of the building. The home is in a residential area of Palmers Green and is close to local shops and businesses. The service aims to provide a supportive and enabling environment to people who have enduring mental health needs. There is a strong emphasis on promoting independence and helping service users establish and maintain family and community networks. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken as part of the annual inspection programme. I sought to confirm that the that the home has continued to provide consitent excellent outcomes for people living at the home. The inspection took place over one day. Pamela Kelly, registered Manager assisted me with the inspection. I spoke with the three people who live at Queen Ann Lodge, and two members of staff. I observed care practice and interaction between people living at the home and staff. I toured the building and examined a number of records relating to the care, health and safety and management of the home. I would like to thank Pamela kelly and all the staff who assisted me by answering questions about the running of the home. I would also like to thank the three people who live at the home who discussed their views of the service they receive. What the service does well:
This key inspection highlighted the continued consistently high standard of care and support provided at Queen Ann lodge. The statement of purpose also identified the skills and staffing resources that are to be available to meet the needs of people living at home. The statement of purpose positively promoted the rights of people living at the home to express their cultural and religious identity. One of the people spoken to told me that he attends church and that staff had supported him doing this. The statement of purpose clearly sets out the philosophy and objectives of the home. Initial assessments seen were carried out with the involvement of the people and their families. A relative commented that since her sister had come to the home she had been, “happy and well cared for.” I found that the needs of the people case tracked had been reviewed both by the home and by social workers. Changes in needs had been addressed to ensure that people receive a consistent level of care to meet their needs. Staff spoken to understood the needs of people and could explain the specific needs of people case tracked. For example, one person case tracked is deaf and uses sign language to communicate. I observed that staff used sign language to communicate with the person. Staff spoken to told me they were
Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 6 about to go on a sign language course to further develop their skills in communicating with this person. I found that care plans had been developed with the involvement of people living at home. People case tracked told me that they had been consulted, and that their views of the support they required was reflected in their care plans. Care plans explained the mental health needs of people and how staff needed to respond to support them. Details of behaviour that might challenge the service of people were identified in their risk assessments and care plans. Actions to address and manage these behaviours are outlined in detail. One person spoken to told me this had helped him to find ways to manage his own aggression. Comprehensive risk assessments are in place to support people living at home to live safely and independently. One person commented that he felt safe in the home. Risk assessments were found to cover all areas that affected the peoples’ daily life. The risk assessments had been agreed with people or their representatives. Risk assessments had been reviewed to ensure changes to the level of risk were addressed. People spoken to said that they could choose from a range of activities. These included visits to the cinema and theatre. There was also keep fit, gardening and visits to the local swimming pool. People spoken to confirmed that they were involved in cleaning of their bedrooms and cooking. I observed people preparing the mid-day meal. People are able to make hot drinks whenever they wish to. Comment cards from relatives confirmed that they were able to visit at any time and see people in private. The menu is prepared at a weekly meeting of people living at home. I saw minutes of these meetings these confirmed that peoples’ suggestions for meals were recorded. People spoken to confirmed that they had been involved in preparing the menu. I saw that meals were well presented and were provided in a relaxed and supportive environment. Medical needs had been identified as part of the initial assessment and were referred to in care plans and risk assessments. Daily notes confirmed that the General Practitioner had been consulted when the people were unwell. Comment cards received from general practitioners who attend the home confirmed that staff have a clear understanding of all the medical and mental health needs of people living in the home. The medication policy contained all the required information. I found that records for the administration of medication were complete. Daily notes showed that community mental health professionals had been consulted to ensure that people were receiving the medicines they required. People told me that they understood how to make a complaint. Copies of the complaints policy were available around the home for people to consult when
Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 7 necessary. Comment cards received from relatives and friends confirm that they were happy with the way in which the home addresses their concerns. Training records showed that staff had received training in adult protection. I spoke with staff and they demonstrated their understanding of adult protection issues. I went round all floors and found that they were appropriately decorated and furnished. There is a dining and sitting area on the ground floor. Bedrooms were personalised with items of furniture and pictures belonging to people who live at the home. People living at home and chosen how they wanted their bedrooms decorated. People spoken to were pleased with their bedrooms. I found that the rota showed that a consistent staffing level was maintained. Current staffing levels are kept under review so that sufficient staff are always available to meet the changing needs of people living at the home. I observed that staff were available at key times of the day (e.g. mealtimes) to assist people. The registered manager provides a varied training programme for staff. The registered person explained that the home has maintained its Investor in People Award. Training records confirmed that all staff were up to date with, and had all the statutory required training. Training records also showed that 85 of staff have either level 2 or 3 in the National Vocational qualification in care. People can be confident that they are protected by the home’s recruitment procedures. People who live at the home are involved in the selection of staff. One person spoken to told me that he had recently attended a recruitment and selection course with members of staff. He explained that he is going to be involved in the interviewing and selection process. The home has a stable management and the registered manager has experience and understanding of the requirements of people with mental health needs. Staff and people spoken to confirmed that they felt that the registered manager was supportive and approachable. The home has a system to monitor the views of the people, on the service that is provided. Ideas for improvement are sought. A quality survey has been carried out of the views of people, relatives and professionals. The registered manager ensures that the safety risks to people living and working at the home are identified. Measures are put in place to provide a safe living and working environment What has improved since the last inspection?
No areas for improvement were identified at the last inspection. The home has consistently met the needs of people living at the home.
Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 8 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 Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 9 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 Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 10 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): 12 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose is an accurate description of the service provided. People’s needs are assessed prior to admission to the home to ensure they receive the care and support required. EVIDENCE: I found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The statement of purpose also identified the skills and staffing resources that are to be available to meet the needs of people living at home. The statement of purpose positively promoted the rights of people living at the home to express their cultural and religious identity. One of the people spoken to told me that he attends church and that staff had supported him in doing this. The statement of purpose clearly sets out the philosophy and objectives of the home. I case tracked people who live at the home and found that there were assessments from the home and care management. These identified the needs of people prior to admission to the home. Examples of the assessments seen were carried out with the involvement of the people and their families. A
Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 11 relative commented that since her sister had come to the she had been, “happy and well cared for.” People told me that they had signed a contract detailing what the home provided. There have been no new admissions since the last key inspection. I found that the needs of the people case tracked had been reviewed both by the home and by social workers. Changes in needs had been addressed to ensure that people receive a consistent level of care to meet their needs. Staff spoken to understood the needs of people and could explain the specific needs of people case tracked. For example, one person case tracked is deaf and uses sign language to communicate. I observed that staff used sign language to communicate with the person. Staff spoken to told me there were about to go on a sign language course to further develop their skills in communicating with this person. I was able to confirm that staff understood the needs of the people who had come to live in the home. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 12 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): 679 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided detailed information on the needs of people living at home. People are supported to make decisions about their lives. Risks to service users are assessed to ensure their safety. EVIDENCE: I found that care plans had been developed with the involvement of people living at home. People case tracked told me that they had been consulted, and that their views of the support they required was reflected in their care plans. Care plans explained the mental health needs of people and how staff needed to respond to support them. People spoken to confirmed they had been involved in reviews of their care plans. People felt that their views and wishes Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 13 were recorded. A key worker system is in place to ensure that people living at home are given individualised support and care. Details of behaviour that might challenge the service of people were identified in their risk assessments and care plans. Actions to address and manage these behaviours are outlined in detail. Where appropriate staff and discussed and recorded the views of those people living at the home whose behaviour might be challenging. One person spoken to told me this had helped him to find ways to manage his own aggression. Staff spoken to understood both the general principles, and specific needs of people living at the home with regards to managing challenging behaviour. Comprehensive risk assessments are in place to support people living at home to live safely and independently. One person commented that he felt safe in the home. Risk assessments were found to cover all areas that affected the peoples’ daily life. Risk assessments identified the specific risk facing individual service users. These are reflected in care plans. Risk assessments are regularly reviewed so that changes in the level of risk to people are addressed. Staff were able to describe how they prevented risks to ensure that service users were safe and were supported to exercise control over how they live. Risks relating to behavioural issues were identified and actions to prevent or lessen the level of risk were discussed. The risk assessments had been agreed with people or their representatives. Risk assessments had been reviewed to ensure changes to the level of risk were addressed. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 14 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 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to engage in a range of activities that meet their needs. Service users have community contacts and are supported to maintain personal relationships. Service users are supported to maintain a nutritious diet that reflects their personal choice. EVIDENCE: People spoken to said that they could choose from a range of activities. These included visits to the cinema and theatre. There was also keep fit, gardening and visits to the local swimming pool. Daily notes and care plans confirmed that service users were regularly involved in activities both in and outside of Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 15 the home. People spoken to told me that they had been consulted about the activities that are being provided. People spoken to confirmed that they were involved in the cleaning of their bedrooms and cooking. People are able to make hot drinks whenever they wish to. Daily records showed that people were supported to maintain contacts with family and friends. People living at home were able to develop contacts in the local community. Comment cards from relatives confirmed that they were able to visit at any time and see people in private. I observed that people went to the shops when they wanted to. The menu is prepared at a weekly meeting of people living at home. I saw minutes of these meetings these confirmed that people suggestions for meals were recorded. People spoken to confirmed that they had been involved in preparing the menu. Staff explained that people living at home are advised how to maintain a healthy and balanced diet. I observed that there were fresh vegetables and fruit available. One person explained that they had been involved in doing the weekly shopping. I saw that meals were well presented and were provided in a relaxed and supportive environment. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 16 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 20 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. People are supported with their personal care needs to maintain their independence. People are able to access the medical care they need. People are protected by safe procedures for handling medication. EVIDENCE: Care plans outlined the support people require and how they could be supported to maintain their independence in doing their personal care. I spoke with people who explained that staff provided support and encouragement to maintain their personal hygiene. Medical needs had been identified as part of the initial assessment and were referred to in care plans and risk assessments. Two people case tracked confirmed that they had received regular support from community mental
Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 17 health professionals. Daily notes confirmed that the General Practitioner had been consulted when the people were unwell. Comment cards received from general practitioners who attend the home confirmed that staff have a clear understanding all the medical and mental health needs of people living in the home. General practitioners also confirmed that staff communicate clearly with them and work cooperatively to ensure that the medical needs of people are addressed. Medical notes showed that people had received medical care from a range of health professionals. Multi-disciplinary reviews had been held to ensure that any changes to the mental health needs of people living at home were thoroughly addressed. Where necessary follow up action had been taken to provide the care and support that people need. The medication policy contained all the required information. I found that records for the administration of medication were complete. Records of medication received and returned were also complete. All medication was held securely. People’s medication had been reviewed regularly to ensure their continued well being. Daily notes showed that community mental health professionals had been consulted to ensure that people were receiving the medicines they required. Medication profiles were in place and had been updated to reflect any changes in peoples ’ medication. Training records and discussions with staff confirmed that they had received training on the safe administration of medicines. Advice was available for staff on the side effects of medication. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 18 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 23 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Service users can be confident that their complaints are listened to and acted upon. Adult protection procedures protect service users from abuse. EVIDENCE: People told me that they understood how to make a complaint. The complaints policy explained how to make a complaint and how it would be dealt with. Copies of the complaints policy were available around the home for people to consult when necessary.The complaints record showed that there had been no complaints. The registered person explained that she regularly talks with friends and relatives of people who live at the home to talk about their views of the service. Comment cards received from relatives and friends confirm that they were happy with the way in which the home addresses their concerns. Any issues that are raised are dealt with immediately. People are encouraged to discuss their views of the service in weekly meetings. People who live at the home told me that they could challenge and raise concerns about the way they were treated. The inspector observed staff
Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 19 approach service users and this was done appropriately and sensitively. There were comprehensive policies on handling abuse and adult protection. Training records showed that staff had received training in adult protection. I spoke with staff and they demonstrated their understanding of adult protection issues. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 20 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 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home that provides a safe and homely environment. The home is clean and hygienic. EVIDENCE: I went round all floors and found that they were appropriately decorated and furnished. There is a dining and sitting area on the ground floor. I observed that people were able to access all areas in the home safely. The home has the necessary adaptations to support people to access all areas safely. Bedrooms were personalised with items of furniture and pictures belonging to people who live at the home. People living at home and chosen how they wanted their bedrooms decorated. People spoken to were pleased with their Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 21 bedrooms and told me they had chosen items to bring with them when coming to live at the home. Appropriate measures are in place to prevent cross infection. The home has detailed policies on the prevention of cross infection. Staff have received training on infection control measures. People living at the home told me they had also been involved in this training and understood the importance of preventing infection. Staff spoken to understood how to work to minimise the possibility of cross infection. Staff confirmed that they had access to disposable gloves and aprons. Liquid soap and paper towels were available throughout the home. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 22 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 35 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Sufficient staff are always available to meet the needs of people. Staff do have all the skills to support people as they are provided with on-going development opportunities. People are protected by the home’s recruitment procedures. EVIDENCE: I found that the rota showed that a consistent staffing level was maintained. The rota also showed that extra staff were on duty to provide escorts to appointments and support with activities. Staff spoken to confirmed that sufficient staff were available at all times. Current staffing levels are kept under review so that sufficient staff are always available to meet the changing needs of people living at the home. I observed that staff were available at key times of the day (e.g. mealtimes) to assist people. Staff were also observed to spend time with people both individually and in small groups. This allowed more attention to the individual needs of people who live at the home.
Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 23 The registered manager provides a varied training programme for staff. The registered person explained that the home has maintained its Investor in People Award. All staff are supported to do some form of training that meets their professional and personal development needs. There is a training development plan that identifies all skills needed by staff to support people living at home. Training is provided so that staff have the skills. The registered manager explained that she is currently carrying out appraisals on all staff so that their individual learning objectives for the year can be identified. Training records confirmed that all staff were up to date with, and had all the statutory required training. Staff had also received training in mental health awareness. All staff have done training on Relapse Prevention in Mental Health. This has further developed their understanding of people with mental health needs and how to prevent them becoming unwell. They commented that the registered manager positively encouraged them to go on training to develop their skills and understanding of the needs of people. The registered manager also ensures that training is available on areas that would support staff in their general development. For example, staff had attended training on using computers and recycling. Training records showed that 85 of staff have either level 2 or 3 in the National Vocational qualification in care. The registered person explained that the deputy managers are doing the Registered Manager Award, National Vocational qualification. The registered person explained that training had been planned to ensure that staff keep up to date with developments in social care. The registered manager has put in place a training plan for the coming year. I found that this ensured that staff continue to have all the necessary skills to meet the needs of the people living in the home. I examined staff files at the last key inspection and found they contained all the necessary documentation relating to the recruitment and appointment of staff. No new staff have been appointed since the last key inspection Staff go through an interview process and there were notes to confirm this. Applicants are invited to the home to meet with people who live at the home before their interviews. People spoken to confirmed that they had been consulted about the recruitment of staff. One person spoken to told me that he had recently attended a recruitment and selection course with members of staff. He explained that he is going to be involved in the interviewing and selection process. People can be confident that they are protected by the home’s recruitment procedures. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 24 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 42 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. The registered manager has the skills and understanding to manage the service in the best interests of people. People’s views of the service are sought and used as the basis for improvement. People to live at home and staff health and safety is always promoted and safeguarded. EVIDENCE: Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 25 The home has a stable management and the registered manager has experience and understanding of the requirements of people with mental health needs. Staff and people spoken to confirmed that they felt that the registered manager was supportive and approachable. I observed the registered manager working with staff and confirmed that she was supportive and understood the needs of people. The registered manager has continued to develop her skills by attending courses on management and care of people with mental health needs. The registered manager has continued to develop the service to meet the needs of people in the home. The home has a system to monitor the views of the people on the service that is provided. Ideas for improvement are sought. A quality survey has been carried out of the views of people, relatives and professionals. People are consulted about how the home is run. Minutes were seen of meetings held with people who live at the home to discuss the quality of the service provided. Action to improve the service had been agreed with people who live at the home. People had been involved in the review of their needs. People commented that they felt confident that their needs are being met. The registered person ensures that the safety risks to people living at the home and staff are identified. Measures are put in place to provide a safe living and working environment. Records showed that fire equipment was tested regularly and maintained. Drills were taking place. The fire risk assessment provides details of potential risks of fire. All health and safety policies were available. Certificates for gas and electrical testing were in date. COSHH guidance was in place and chemicals were stored safely. Training on health and safety topics was complete. People living at home have been involved in identifying safety issues. Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 26 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 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 x 4 X 4 X X 4 x Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Ann Lodge DS0000010703.V337123.R01.S.doc Version 5.2 Page 29 - 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!
