Inspection on 21/09/06 for Queen Elizabeth's Foundation Brain Injury Centre

This inspection was carried out on 21st September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queen Elizabeth's Foundation... 07/09/09

Queen Elizabeth's Foundation... 26/09/07

Queen Elizabeth's Foundation... 09/01/06

Queen Elizabeth's Foundation... 19/09/05

Queen Elizabeth's Foundation... 01/11/04

Queen Elizabeth's Foundation... 19/08/04

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 HOME ADULTS 18-65 Queen Elizabeth Foundation Brain Injury Centre Banstead Place Park Road Banstead Surrey SM7 3EE Lead Inspector Lisa Johnson Unannounced Inspection 21 September 2006 10:00 Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.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 Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.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 Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth Foundation Brain Injury Centre Address Banstead Place Park Road Banstead Surrey SM7 3EE 01737 356222 01737 359467 rehab@braininjurycentre.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 Elizabeth`s Foundation Lynne April Hensor Care Home 28 Category(ies) of Physical disability (28) registration, with number of places Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 16-36 YEARS 19th September 2005 Date of last inspection Brief Description of the Service: Queen Elizabeth Brain Injury Centre is a residential and education facility in Banstead Surrey and offers rehabilitation and education for young adults who have acquired disabilities or associated learning difficulties as a result of brain injury. Clients from all over the U.K access the service, and it is owned and run by a charity. The maximum number of clients that the service is able to accommodate is twenty-eight. The average length of stay is twelve to eighteen months, although each case is assessed individually. Most of the service users bedrooms are on the ground floor, with a few bedrooms situated on the first floor. All the bedrooms are for single occupancy. Some rooms and accommodation are equipped for independent living. A large multi-disciplinary team supports clients. Annual fees range from £78,795-£102.959 per annum. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over eight hours commencing at nine o’clock and finishing at five o’clock and was carried out by Mrs. L Johnson Regulation Inspector. The inspector spoke to five service users to gain their views on the care provided. Three relative comment cards and three comment cards were received from health care professionals have been received since this site visit and these comments have been reflected in this report. A full tour of the premises took place. Staff training records, staff files and policies and procedures were sampled. The inspector spoke to two members of staff. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: The centre provides accommodation, rehabilitation and education to clients in a good, supportive environment. The environment is adapted to the needs of clients with mobility difficulties and includes adapted kitchens and bathrooms, which assist individuals to develop and maintain their independence. A wide range of health care professionals, recreational and rehabilitation staff support the needs of clients. Clients are involved and supported with decision making which was evident by their involvement with care reviews and a range of meetings held in the centre. Clients are supported to access a wide range of recreational and leisure activities, which meets their individual needs and preferences. Therapies and activities provided include for example physiotherapy, speech therapy, occupational therapy, painting, woodwork, education, hydrotherapy, shopping, theatre trips, day trips and during the site visit a number of individuals were going to the cinema. Clients spoken to were happy with the care and support received at the centre and comments included “This is a good place here” and “The staff are good”. Three comment cards received from relatives concluded that they are satisfied with the care provided to their relatives. One relative commented said “ It’s a great place and the staff are caring”. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 6 Staff are supported to access a range of training and development programmes which is relevant and ensures that staff have the information they require to meet the needs of clients Staff spoken to during this site visited said that the training provided is good. The centre is currently being assessed for the Investors in People Award. What has improved since the last inspection? What they could do better: The inspector examined the homes medication administration systems, which indicated that some areas require improvement. One individual receives leave medication that is secondary dispensed from the original container into a medidose box. There was no risk assessment in place. An immediate requirement was made that a risk assessment is completed to ensure the health and safety of service users. Since this site visit the registered manager has confirmed to the Commission for Social care Inspection that this matter has been completed. However it is further required that the home discusses the practice of secondary dispensing with the local pharmacist to ensure the health, safety and well being of clients. There were a number medication administration cards that had been hand transcribed by staff and it was observed that the name of the member of staff who has transcribed this medication had not been recorded. An immediate requirement was made that this information is recorded with a further recommendation that where possible two members of staff should check the prescription. This is to ensure the heath and safety of service users. Since this site visit the registered manager has confirmed that this matter has been actioned. A requirement was made that two items of medication not being used and that were out of date should be disposed of. It was further required that the centre should obtain a copy of the Royal Pharmaceutical guidelines and that a list is Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 7 maintained of the trained staff authorized to administer medication to be made available with the medication administration records. A number of clients bring homely remedies and vitamins into the unit. It is required that authorization is gained from the GP for all homely remedies and vitamin tablets administered. 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 Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 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 Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of service users are assessed prior to admission to the home. EVIDENCE: Evidence sampled concluded that pre admission assessments are completed prior to any individual moving into the centre. Prospective service users are provided with the opportunity to attend the unit for pre- admission assessment over two days, which is completed by the multi- disciplinary team. Assessments sampled were detailed and informative. The inspector had the opportunity to speak to two individuals who had recently moved into the centre who confirmed that had visited the service before admission. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with an individual care plan, which records their individual needs and goals. Service users are supported to make decisions about their lives with assistance. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: An orientation meeting is held each morning. Each individual has a completed care plan, which has been based on a full needs assessment including personal care, health, mobility, emotional and social needs. Plans were detailed and structured with clear long and short-term objectives. There is a multidisciplinary approach to care as part of the rehabilitation process. It was evident that regular care reviews take place and case conferences are held. One plan sampled had been signed by the individual ensuring that they are fully involved in the process. Individuals have a programme tutor who reviews their progress with them each week and sets targets for the following week. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 11 Detailed risk plans and guidelines were in place, which were sampled and included assessments for health needs, behaviour intervention, daily living skills and community access. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are provided with a range of appropriate activities and engage in a range of leisure activities. Service uses are supported to take part in the local community. The rights and responsibilities of service users is respected. The home is able to demonstrate that service users are provided with a wellbalanced and nutritious diet. EVIDENCE: As part of the rehabilitation programme it was observed that clients have access to a range of fulfilling activities and social events, which are tailored to meet individual’s needs and preferences. Clients are supported with a range of programmes through out the day by care staff, recreational teams and health professionals to develop communication, emotional and independent living skills. The centre provides educational and vocational studies. There are facilities for clients to live in a supported living environment before moving on to more independent living. Adapted kitchens are available where clients have the opportunity to budget, shop and cook. Individual plans were sampled for three clients, which concluded that they are supported with a range of therapeutic interventions including physiotherapy, speech therapy, art therapy memory groups, letter writing, pottery, gardening Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 13 and further education. One Individual told the inspector “I am receiving speech therapy and physiotherapy to help improve my speech and mobility”. Two other individuals spoken to state, “I like to go shopping” and “I go to Pottery”. Depending on individual needs there are opportunities for attending college work experience and use of public transport. Social events in the centre include opportunities for example visits the pub going to restaurants, swimming, trampolining, shopping, day trips, horse riding, gym and barbecues. During the site visit clients and staff were enjoying a game of cricket and in the evening a number of clients were going on a cinema trip. Computers are available for the use of clients and pool tables were observed in the recreational areas Some individuals go home to visit their families at weekends. Telephones and computers are available for clients to access to maintain contact with their families and friends. Comments received from relatives conclude that they are made to feel welcome when they visit the centre and are able to visit in private. During the site visit staff were observed to be respectful to clients and interacting in a positive manner. Clients and staff were observed to have their meals together and staff were seen knocking on individuals bedroom doors before entering. The staff team were observed to be accessible and supportive and responsive to the needs of individuals. The inspector had the opportunity to speak to the key workers for three individuals who had a good knowledge of the needs and preferences of clients. Clients are given the opportunity where possible to handle their own finances and where this is not possible support is provided. Since the previous site visit the dining area has been redeveloped making this area a comfortable area to take meals. There is a chef in post and a varied menu was available based on preferences and the nutritional needs of individuals. A good choice of meals is offered which were well presented and well balanced. Clients in the transitional and independent living units have the opportunity to cook their own meals. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users receive personal support in the way they prefer. Service users physical and health needs are met. Some matters need to ensure that users are protected by the homes medication administration procedures EVIDENCE: The health care needs of clients were documented in their individual care plans, which outline the strengths and needs of individuals and care interventions. Clients are provided with a range of aids and equipment to maximise independence. Key workers spoken to were clear about the needs of individuals and their likes and dislikes. One individual spoken to said she likes to have makeup and nail sessions which staff assist her with. Three individual plans were sampled which concluded that service users are supported to access a range of health care professionals including for example local General Practitioner, dentist, chiropodist and access to optical services. The centre provides rehabilitation so enabling clients to access professional support from occupational therapy, physiotherapy, speech therapy and psychology. Records ware maintained of all health consultations with daily records appropriately maintained. Three comment cards received from health care professionals concluded that staff work in partnership with them and that Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 15 staff demonstrate a clear understanding of the care needs of individuals and that specialist advice is incorporated into the care plan. The homes medication administration systems were examined photographs of some individuals were available with their medication card. Medication cards sampled concluded that medication administered was signed for. There is a medication administration policy in place and staff receive appropriate training. Boots supplies medication in blister packs. Disposal records were in place and medication was stored appropriately. One individual self medicates and a risk assessment is in place. Protocols were in place for the administration of as required medication. However some matters were identified that need improvement. Two-medication administration cards sampled had been handwritten on the medication administration card staff. The member of staff had not signed the medication card. An immediate requirement was made that the all medication that is hand transcribed on to the medication card should be signed and dated by the member of staff who is qualified to administer medication with a further recommendation that two staff should check and sign where possible. This is to ensure the health, welfare and safety of clients. Since this site visit the registered manager has confirmed that this matter has been actioned. One individual receives leave medication that was secondary dispensed from the original container into a redidose box and there was no risk assessment in place for the safe administration for the secondary dispensing. An immediate requirement was made that the home should ensure that a safe system including a risk assessment should be completed for the safe administration of the secondary dispensed medication. Since this site visit the registered manager has provided written confirmation that this matter has been completed. It is further required that the practice of secondary dispensing should be discussed with the local chemist to ensure the health, wellbeing and safety of clients. A requirement was made that two items of medication that were not being administered and were out of date should be disposed of. A further requirement was made that the service should obtain a copy of the Royal Pharmaceutical guidelines. It was recommended that the service maintain a list of the trained staff authorized to administer medication with the medication administration records, as this was not available during this inspection. A number of clients bring homely remedies and vitamins into the unit. It is required that authorization is gained from the GP for the administration of all homely remedies and vitamin tablets. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of service users are listened to and acted upon. The staff team need to ensure that it responds to the protection of vulnerable adult policies to ensure that residents are protected from abuse. EVIDENCE: There is a complaints procedure in place, which made available to clients with an introduction pack on admission to the centre. The centre has not received any complaints since the previous site visit. The inspector spoke to three service users to gain their views on the care provided. One client said, “It’s a good place here” and another individual said the “Staff are nice” Three comment cards received from relatives indicated that they were satisfied with the care provided by the centre with two relatives confirming that they were aware of the homes complaints procedure. Staff training records indicate that staff have received training in safeguarding adults from abuse and the manager has attended the local authority safeguarding adult training. The home has a copy of the local authority multiagency safeguarding adult’s procedure and the centre has its own policy is in place. Since the previous site visit one matter was referred under the local authority multi- agency safeguarding adult procedure. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 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, 29 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a well-maintained, comfortable, homely and safe environment. The home is able to demonstrate that service users bedrooms promote their independence. The home is clean and hygienic ensuring that service users have a pleasant home to live in. EVIDENCE: During this site visit the inspector toured the premises and it was clear that the physical environment meets the individual requirements of the clients that live there. The home is spacious and well maintained. The service provides wellmaintained grounds, which has a basketball court available. In the transitional unit kitchens and equipment has been adapted to ensure accessibility. There is a cafeteria, which has been recently refurbished with a new kitchen installed. The service also provides a number of recreational rooms and therapeutic areas including a physiotherapy department, further education and therapy departments. The centre is accessible to clients with physical disabilities, adaptations and specialist equipment is provided which includes automatic doors, rails, tracking, and adapted bathrooms. During the inspection pictures and signs Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 18 were on display and the kitchen cupboards were labelled indicating the contents of the cupboards. Bedrooms were viewed as comfortable and personalised and some areas have been refurbished to include kitchenettes to assist clients in increasing their independence. The home was cleaned to a good standard and was hygienic. Separate laundry facilities were available. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 19 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 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent and qualified staff support service users. Service users are protected by the homes recruitment policy and practices and their needs are met by appropriately trained staff. EVIDENCE: During the site visit adequate staffing levels were maintained with seven staff on duty. Due to the current reduction in the number of clients using the centre there has been a reduction of the number of care staff on duty. The service provides a recreational team of staff who support clients with social and recreational needs. During discussions with staff some staff felt that staffing levels were not always sufficient at weekends. The inspector was informed that a number of clients go home at weekends. However it was recommended that the staffing levels provided at weekends be kept under review. The centre provides a varied and good range of training available, which was confirmed by staff spoken to who said the training is “good”. The inspector sampled the training schedule, which concluded that staff receives regular mandatory training including for example first aid, food hygiene, moving and handling, safeguarding adults and infection control. The centre provides induction training for new staff and the programme was shown to the inspector that indicated that a detailed and comprehensive plan was in place. The centre is able to demonstrate that staff receive training and development, which actively supports the needs of clients including training for brain injury Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 20 awareness, disability awareness, conflict and aggression and a clinical assistant carries out training in epilepsy and diabetes. Evidence was provided that staff are actively supported to gain National Vocational Qualifications (level 2) or above. The home is currently being assessed by Investors In People. Four staff personal files were sampled which were maintained to a good standard and contained the required information. POVA first checks are carried out and enhanced police checks are completed with appropriate records maintained. The inspector sampled the supervision records for four members of staff, which concluded that staff receive, receive regular formal supervision. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that service users benefit from a home, which is well run, and in the best interests of service users. The health, welfare and safety of service uses is protected. EVIDENCE: The registered manager is a qualified nurse and has completed the Registered Managers Award. The manager has also completed a degree in psychology and holds a master’s degree in counselling psychology. The manager was unavailable during this site visit, but the inspector had the opportunity to speak to the acting manager in the residential units who had the relevant experience, training and qualifications to take charge of this area. Staff spoken to felt supported by the management structure in place and it was evident that regular staff meetings take place. The inspector had the opportunity to speak to the quality assurance coordinator. Quality assurance questionnaires have been updated with the Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 22 outcomes analyzed with feedback provided to clients. The centre is in the process of updating policies and procedures. Regular consultation takes place with clients with daily meetings taking place. The home has implemented a quality assurance cycle that was made available to the inspector and the home is also inspected by OFSTED. Substances hazardous to health (COSHH) were stored Health and safety checks are completed and recorded and fire records were appropriately maintained. Examination of records and certificates identified systems are in place for routine service and maintenance arrangements for the environment. The centre has received a positive inspection from environmental health Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.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 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 X 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 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 3 27 X 28 X 29 4 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000013754.V309379.R01.S.doc 3 3 X 3 X LIFESTYLES Standard No Score 11 4 12 4 13 X 14 X 15 3 16 X 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 X 3 X 3 X X 3 X Version 5.2 Page 24 Queen Elizabeth Foundation Brain Injury Centre Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement a) The registered person must ensure that the medication that is out of date must disposed of. b) All home remedies dispensed in the home must be authorized by the GP c) The administration of vitamins and supplements must be authorized by the GP d) The centre must obtain a copy of the Royal Society Pharmaceutical guidelines. e) The practice of secondary dispensing medication from the original containers must be discussed with the local pharmacist. Timescale for action 22/10/06 Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 25 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 Refer to Standard YA20 Good Practice Recommendations a) It is recommended that an updated list of staff that are trained to administer medication is made available with the medication administration records. b) It is recommended that two staff two staff should check the medication administration record when medication is hand transcribed. The registered manager should consider keeping the staffing levels under review at the weekend. 2 YA33 Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Elizabeth Foundation Brain Injury Centre DS0000013754.V309379.R01.S.doc Version 5.2 Page 27 - 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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