CARE HOME ADULTS 18-65
Queen Elizabeth Foundation Brain Injury Centre Banstead Place Park Road Banstead Surrey SM7 3EE Lead Inspector
Lisa Johnson Announced Inspection 9th January 2006 10:00
Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 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.V270099.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V270099.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Queen Elizabeth Foundation Brain Injury Centre Address Banstead Place Park Road Banstead Surrey SM7 3EE 01737 356222 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.V270099.R01.S.doc Version 5.1 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. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was announced and the second in The Commission for Social Care Inspection programme year 2005/2006. Mary Williamson Regulation Inspector undertook the inspection, as The Lead Inspector for the service Lisa Johnson was unwell on the day of the inspection. The registered manager Lynne Hensor was the designated representative for the service for the duration of the inspection. Seven Service User, eight Relative, four Health and Social Care Professionals, one Care Manager and one GP comment cards were received. They all had positive and encouraging comments and feedback about the home and the care provided. A tour of the premises was undertaken, and records relating to the care of the service users and the management of the home were examined. There was opportunity to talk with the service users during the inspection who were all keen to share their experiences about living in the home. The general feedback regarding their care, recreation and education was positive. The inspector spoke with several members of staff who confirmed they had undertaken induction and health and safety training. The inspector would like to thank the service users and staff for their hospitality ant their positive input to the inspection process. What the service does well:
The service provides accommodation a balance of neuro-rehabilation, and education to service users in a well-structured environment. The quality of care and support provided is good as outlined in well- documented care plans. The standard of accommodation is good with service users bedrooms being personalised to reflect individual personalities. There is ample communal space available which is well equipped. The home is adapted to meet the mobility needs of service users. This includes adapted bathrooms and kitchens. Health care needs are catered for with support from a number of health professionals to include physiotherapy, occupational therapy, GP, district nurses and psychology.
Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 6 The service has a recreational department offering a wide and varied range of activities, which includes going to the cinema, pub, swimming, bowling, visiting restaurants and shopping. One service user stated that he enjoyed going to the pub to watch Sky Sports. 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
Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 7 contacting your local CSCI office. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 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.V270099.R01.S.doc Version 5.1 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): 1, 2, 4, and 5. Prospective service users and their families have the information necessary available to them to make an informed choice regarding the home. A detailed pre admission needs assessment and staggered admission process is in operation. Written contracts are also in place. EVIDENCE: All service users and their families have access to a statement of purpose and service users guide prior to admission to the home. This enables prospective service users to make an informed decision about the placement and the facilities available to them. The multidisciplinary team prior to admission undertakes comprehensive pre admission needs assessments. This assessment is undertaken over a period of two days in the unit, and includes all heads of departments. Written contracts are in place between the funding authority, service user and the unit. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9, Individual care plans outline the personal, social and emotional needs of service users. Assessments are in place for identified risks regarding decisions service users make activities they wish to take part in. EVIDENCE: Individual care plans are in place, which are informative, detailed and well maintained. These plans are written with input from the service users, information obtained from the pre admission needs assessment, and contribution from the multidisciplinary team. Health, social and emotional needs are outlined in these plans. All service users are registered with a local GP. There is also access to a local dentist. The plans also include rehabilitation and therapeutic interventions, which are all provided on site by physiotherapists and the rehabilitation team. Each service user has a programme tutor who reviews their progress with them weekly, and sets targets for the following week. Case conferences are held every Thursday on a rotation basis. Risk assessments are in place, which include assessments for moving and handling, behaviour intervention, daily living skills, and community participation. Frequent meetings are facilitated to discuss any concerns, listen to suggestions, and air each other’s views.
Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 11 Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, and 17, Service users have opportunity for personal development, to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Nutritional needs are met. EVIDENCE: There is a recreational team of staff in place, who facilitate and oversees the individual and collective social and recreational needs of service users. They are supported with a range of programmes throughout the day to develop communication, and independent living skills. Individuals are encouraged to shop for and prepare meals in specially adapted kitchens for small groups. There are facilities in place for service users to live in a supported living arrangement prior to progressing to independent living. One service user was clearly enjoying this experience and was able to demonstrate this to the inspector. Other activities include trips to the pub, shopping, swimming, cinema, trampoline, trips to the coast, music evenings going to restaurants, and watching football on Sky in the local pub. The service users have access to computers and opportunity to e-mail their friends and family.
Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 13 Family links are maintained and some of the service users go home for weekends. Relatives are also included in the care planning process. There is a full time chef in post who oversees the catering arrangements in the home. He plans the menus based on the knowledge of preferences and nutritional needs of the service users. A choice of dishes is offered at all meals. There is currently redevelopment in progress, which included a new kitchen and dining hall. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 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): 19, and 20 Personal and health care support is planned and provided in a sensitive manner. The service users are protected by the homes medication administration procedures. EVIDENCE: Health and emotional needs are supported as outlined in individual care plans. Service users have access to a GP at Longcroft Health Centre during term time. There is also access to a dentist, and optician when required. Physiotherapy, occupational therapy, and psychology are all provided on site as part of the rehabilitation programme. The home has a policy in place for the administration of medication. The medication recording charts were seen and these are well maintained. The home has a system in place for a short summery of needs and a photograph on the front page of these charts to be used in an emergency if a service user had to go to hospital. Medication is supplied by Boots the Chemist in blister pack format. Currently three service users self medicate and risk assessments are in place for this procedure. All medication is stored appropriately and a record of the fridge temperature, which is used to store medication, is kept. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 15 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, and 23. There is a complaints procedure in place, which is assessable to all service users. The adult protection procedures in place protect the service users. EVIDENCE: There is a complaints procedure in place. This is available to all service users and their relatives on admission to the home. There have been no complaints since the last inspection. The home has a copy of Surrey’s Multi- Agency Procedures on the Protection of Vulnerable Procedures in place. The manager stated that she has attended this training twice. The home also has an abuse awareness policy in place and all staff have training in abuse awareness during induction training. The manager stated that the bank staff are now also included in this training. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 16 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, 25, 26, 27, 28, 29,and 30 These standards remain unchanged. Please see the previous inspection report dated 19th September 2005. EVIDENCE: Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 17 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, and 34. Staffing levels are kept under review to meet assessed needs of service users. The home’s recruitment policy protects the service users however it was not possible to view employment records. EVIDENCE: Interaction observed between staff and service users evidenced a high degree of skill and mutual respect in working with this service user group. The staff duty rotas were seen and indicated a good skill mix of staff on duty during the inspection. Staffing levels are kept under review to meet assessed needs. There is a robust recruitment procedure in place, which was seen. This includes an equal opportunities policy, and a staff handbook. The home employs a human resources person responsible for the maintenance of all employment records and documentation. It was after lunch by the time the inspector had capacity to assess standard 34. It was not possible to view employment files as the person responsible had gone off duty with the key to the filling cabinet where these documents are stored. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, and 42. Service users benefit from a well managed home providing an open and inclusive approach atmosphere. Quality assurance is monitored and health and welfare promoted. EVIDENCE: The registered manager is a qualified nurse and has a degree in psychology and also holds a masters degree in Counselling Psychology. The manager has also completed the Registered Managers Award. She promotes an open and inclusive management approach in the home. Staff meetings take place two weekly and staff stated that they felt comfortable with the management structure within the home. There is a quality assurance coordinator in post who monitors all service provided. Service users and staff complete yearly questionnaires. There is also an exit questionnaire completed by service users on discharge. There is a suggestion box available and also daily service user meetings and regular review of care. The home is also inspected by OFSTED. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 19 The maintenance of records is good. Records sampled included care plans, medication recording charts, menus, CRB disclosure list, risk assessments and needs assessments. The staff employment records were not available. There is a wide range of health and safety policies and procedures in place, which protect the health and welfare of the service users living at the home. The fire safety records were examined and were well maintained. There is a contract in place for the maintenance of fire fighting equipment. The accident records were well maintained. Queen Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 20 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 3 5 3 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43
DS0000013754.V270099.R01.S.doc 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X 3 X 2 3 X
Version 5.1 Page 21 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 YA34 and 41 Regulation 17(3) Requirement Timescale for action 17/02/06 2. YA36 18(2) The registered person must ensure that all documents listed in Schedule 2 are available in the home at all times for inspection by The Commission for Social Care Inspection. All staff in the service must 17/02/06 recieve formal, documented supervision sessions at least six times a year to ensure that staff are given the support they need to carry out their job. These documents must be available as evidence. 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 Elizabeth Foundation Brain Injury Centre DS0000013754.V270099.R01.S.doc Version 5.1 Page 22 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
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