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Inspection on 07/09/09 for Queen Elizabeth's Foundation Brain Injury Centre

Also see our care home review for Queen Elizabeth's Foundation Brain Injury Centre for more information

This inspection was carried out on 7th September 2009.

It is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Excellent.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Annual service review Name of Service: Queen Elizabeth Foundation Brain Injury Centre The quality rating for this care home is: The rating was made on: three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Lisa Johnson Date of this annual service review: 0 7 0 9 2 0 0 9 Annual Service Review Page 1 of 7 Information about the service Address of service: Banstead Place Park Road Banstead Surrey SM7 3EE 01737356222 01737359467 lynne.hensor@braininjurycentre.org.uk www.gefd.org Queen Elizabeth`s Foundation Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : physical disability Conditions of registration: Number of places (if applicable): Under 65 Over 65 28 0 The maximum number of service users who can be accommodated is: 28 The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Physical disability (PD) Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Queen Elizabeths Foundation Brain Injury Centre is a residential and education facility in Banstead Surrey which 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 the Queen Elizabeths Foundation, a registered charity. The maximum number of clients that the service is able to accommodate residentially is 28. The average length of stay is twelve Annual Service Review Page 2 of 7 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 other accommodation are equipped for independent living. A multi-disciplinary team supports clients. Annual fees at the time of this inspection ranged from approximately £81,600 -£119,00 per annum dependant upon assessed needs. Separate fees apply for the two day assessment - the vocational programme is an intrinsic part of the rehabilitation programme for all clients. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Surveys returned to us by people using the service and from other people with an interest in the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. What other people have told us about the service. What has this told us about the service? The last key inspection was carried on 26th September 2007 and an annual service review was conducted on 18th September 2008. The registered manager returned a clear and comprehensive annual quality assurance assessment (AQAA). The self-assessment identified areas that had improved in the last year and others where further developments were being planned, which would benefit people using the service. Information supplied in the AQAA states that that the service continues to have an established admissions procedure to ensure that they are able to meet peoples needs. Following preliminary assessments case conferences are held with the multi disciplinary team to discuss peoples needs for rehabilitation and suitability for a programme at the centre, which includes the persons views. Each person has a care plan, which is compiled by the rehabilitation support team in consultation with people. Over the last year the service has reviewed and improved future planning processes for people and the use of IT to support peoples understanding of their progress . Risk assessments are completed prior to admission to the service and they are regularly reviewed in light of peoples changing needs. These include, mobility risk assessments, recreational activities and suitability to selfadminister medication. The service is intending to review the current risk assessment training to ensure that it meets the requirements of current legislation. Annual Service Review Page 4 of 7 Staff receive training in culture and diversity and people using the service are involved in recreational diversity groups, where there is a student representative is in place. The AQAA states that peoples religious and dietary preferences are respected. People also take part in equality and diversity awareness training as part of the Staying safe element of their induction programme. The centre celebrates culturally diverse events such as religious holidays. The service continues to support people to participate in a varied range of vocational, educational, therapeutic, recreational and social activities. This includes internal and external work placements, attending job fairs and seminars and attending college. People are supported to explore and plan specific activities of their choice and to access the community more independently. Over the last year the service has increased the number of accredited courses including OCR Literacy, numeracy and ICT, bookkeeping, arts award and Coachability. More diverse activities are on offer to meet the needs and wishes of people including access to a sensory room in the community and introduction of a radio room ,with plans to set up a radio station. Over the last year more people have been involved in menu planning and healthy eating sessions and weekend meal options have been revised to accommodate the wishes of people. Five out of seven surveys received from people using the service indicated that are able to do what they want to do during the day, evenings and weekends. Comments included, I find there is a welcoming atmosphere at the centre and there is a wide variety of activities on the timetable;I do enjoy myself at the Centre and I would like to have sky television, more choices of things to do outside of therapy sessions that are more wheelchair friendly. Another person identified that meals could be improved. The AQAA states that that the service has revised the format of their care plans to ensure that peoples needs and preferences for support are met. The number of people self administering their medication has increased. Four feedback surveys from external health and social care professionals, stated that peoples health and social care needs are properly monitored, reviewed and met Comments included, The Queen Elizabeths Foundation is extremely well administered and due regard is paid to people who have complex needsand My experience of the service has been positive. A person using the service said, The Centre cares for you in every way possible to the highest extent and always offers support in everything that you do. Information supplied in the AQAA states that the Centre has received four complaints, which were resolved with agreed timescales. Staff receive safeguarding training and to use non contact de-escalation techniques. Two safeguarding referrals have been made following the local authority safeguarding vulnerable adults from abuse procedures. One of these matters was accepted by the local authority, although from their investigations this did not warrent further action through the local authority procedures. Seven people surveyed said that they were aware of the complaints procedure, know who to speak to if they had any concerns, staff listen to what they say. and that staff treat them well. One person said, There are friendly people and there is a good atmosphere. Annual Service Review Page 5 of 7 Over the last year a new wing has been opened in the centre offering additional educational, vocational, social and therapeutic opportunities for people. There is an ongoing refurbishment programme. Six out of seven people surveyed said that the Centre is clean and fresh, although one person said that cleanliness needs improving in the group home. The service continues to be run by an experienced registered manager, who is a registered nurse, chartered psychologist and holds the registered Managers Award National Vocational Qualification (Level 4). People using the service continue to benefit from a stable staff team, where there has been minimal staff turnover in the last year. Information supplied in the AQAA states that forty two percent of care staff hold National Vocational Qualifications (Level 2) or above. Three members of staff are currently studying for National Vocational Qualification (Level 2) and two are studying National Vocational Qualification (Level 3). Staff continue to receive regular training and development to ensure that they are able to meet the needs of people using the service,which includes mandatory as well as specialist training. Over the last year the training programme has been reviewed, which has included Mental Capacity Act and deprivation of liberty safeguards and equality and diversity. New staff receive induction following the Skills for Care core induction standards.A member of staff surveyed said, that they have enough support, experience and knowledge to meet the differing needs of people living at the centre and receive support from their manager, although communication between therapy and care staff could be improved The service continues to gain the views of people using the service through annual satisfaction surveys, weekly programme tutor sessions, three monthly review and feedback forms, regular manager meetings and equality and diversity groups. Health and safety has been considered in the AQAA including, staff training, policies and procedures, accident/incident recording, risk assessments and further information supplied indicates that servicing and maintenance of equipment is up to date . Security at the side and front of the building has improved with new fencing installed. The service continues to let us know about things that have happened since our last key inspection. What are we going to do as a result of this annual service review? We are not going to change our inspection plan and we will do a key inspection by 26/09/10 However we can inspect the service at anytime if we have any concerns about the quality of the service or the safety of people using the service. Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Annual Service Review Page 7 of 7 - 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. 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