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Inspection on 25/10/06 for Queen Elizabeth House

Also see our care home review for Queen Elizabeth House for more information

This inspection was carried out on 25th October 2006.

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

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

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

What the care home does well

This home takes a lot of effort when filling vacant beds to make sure that any prospective Service User has the information they need to make an informed decision about the home and that they are properly assessed. Care plans are detailed and regularly reviewed and are signed by the Service User as well as staff. Service Users are given many opportunities to comment on the service offered by the home. There is an annual quality assurance survey and tenant meetings, also after meals residents on each table are encouraged to comment on the back of the menu card about the meal and to make suggestions for future menus, on one occasion so many people complained about the meatballs that the chef apologised and promised not to cook them again! When Service Users attend organised activities they are asked to sign the activity sheet and say whether they enjoyed themselves. The home is comfortable and homelike, it has its own maintenance man who carries out repairs and follows a rolling program of redecoration and maintaining the building. It is kept to a high standard and the home is tastefully decorated throughout. A lot of effort is put into arranging meaningful activities inside the home and out of it. Service Users speak highly of the Manager and says that she tries very hard to make their life as comfortable as possible. While talking with the Inspector the Manager said that she was always looking for ways to improve the service and was mindful of the staffs needs as well as the Service Users.

What has improved since the last inspection?

The Home has achieved the Investor in People Award and held a party to celebrate it. Areas of the home and some of the bedrooms have been redecorated and refurbished. The Manager has recruited more senior care staff since the last Inspection so that there are sufficient numbers to enable the Manager to rota a senior staff onto night duty so as to better monitor the service. The Manager now has the same person supervise her regularly as opposed to having a different manager each time.

What the care home could do better:

The home is located in a desirable residential area, but it makes it difficult to attract and keep staff as it is not close to a town centre or on a regular bus route, the nearest bus stop is a good walk away and people travelling home after a late shift feel that it is too isolated and feel unsafe, staff often site this as a reason to leave. The Manager is seeking ways to recruit and retain staff from the local population; in the meantime she is looking elsewhere for good quality staff.

CARE HOMES FOR OLDER PEOPLE Queen Elizabeth House 38 Southborough Road Bickley Kent BR1 2EE Lead Inspector Ann Wiseman Unannounced Inspection 25th October 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth House Address 38 Southborough Road Bickley Kent BR1 2EE 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 8467 3994 020 8467 7660 Greensleeves Homes Trust Ms Asvinta Thakkar Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: Queen Elizabeth House is a two-storey, purpose built care home for older people. The provider is Greensleeves Homes Trust. The home is set back from a busy main road, in a residential area. There is a bus stop outside the home and Bickley mainline rail station is within walking distance. The home is near to local shops. The building has parking space at the front and a garden at the back, with raised flowerbeds, lawn and patio. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and consisted of two site visits, The Inspector talked to Service Users privately and collectively and sent user surveys to the Service Users, their families, professionals involved and survey letters to the staff, the response to the surveys was good, with positive comments. The Inspector arrived at 8.30am before the manager came on duty and the home was found to be clean and tidy with a calm atmosphere, the Service Users were eating breakfast and they all seemed to be enjoying it. The Residents reported that they were happy with the way the home was run; that they found it comfortable and that they felt their needs were met. They are given many opportunities to comment on the quality of the service. The Manager is capable and well organised and has ensured that the home has consistently offered a good quality service to its Residents over recent years. What the service does well: This home takes a lot of effort when filling vacant beds to make sure that any prospective Service User has the information they need to make an informed decision about the home and that they are properly assessed. Care plans are detailed and regularly reviewed and are signed by the Service User as well as staff. Service Users are given many opportunities to comment on the service offered by the home. There is an annual quality assurance survey and tenant meetings, also after meals residents on each table are encouraged to comment on the back of the menu card about the meal and to make suggestions for future menus, on one occasion so many people complained about the meatballs that the chef apologised and promised not to cook them again! When Service Users attend organised activities they are asked to sign the activity sheet and say whether they enjoyed themselves. The home is comfortable and homelike, it has its own maintenance man who carries out repairs and follows a rolling program of redecoration and maintaining the building. It is kept to a high standard and the home is tastefully decorated throughout. A lot of effort is put into arranging meaningful activities inside the home and out of it. Service Users speak highly of the Manager and says that she tries very hard to make their life as comfortable as possible. While talking with the Inspector the Manager said that she was always looking for ways to improve the service and was mindful of the staffs needs as well as the Service Users. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of these standards were addressed on this occasion. Quality in this outcome area is excellent. This judgment had been made using available evidence including a visit to this service. Prospective Service Users can fell confident that they will be given full and comprehensive information about the home, have an opportunity to visit and will have their needs assessed. EVIDENCE: Queen Elizabeth House has a waiting list and as vacancies occur the prospective Service User and their family will be invited to visit the home for the morning or afternoon. They will meet with the Manager and are introduced to the Service Users and will have an opportunity to spend time in the room they will occupy. During the visit they will be given the homes comprehensive brochure that incorporates their Statement of Purpose and Service User’s Guide. The brochure is well written and attractively laid out. The Statement of Purpose is reviewed annually and the Commission is routinely sent a copy of the document. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 9 While visiting the home a staff member will be allocated to the Service User to answer questions and to look after them. A care need assessment is done that is very detailed and asks about the person’s background, their hopes and expectations for the future as well as their present needs. The home is not under any pressure to fill vacancies and is able keep a room empty for while so the Manager can make sure that the people who move in are best suited to the home and that it will be able to meet their needs. She suggests alternative care homes to those she can’t offer a room. No decision is made on the day of the visit, the home will contact the Service User’s doctor and other professionals involved to gather as full a picture as possible. A financial assessment will also be carried out. If it becomes apparent that the prospective Service User needs support the Manager will refer them to charitable organizations that specialize in advising older people. One Service User the Inspector spoke with said that she was coming to the end of a two-week stay; she was testing the home before she made a decision to stay. She also said that the staff were kind and had made her stay comfortable and that she believed that she would move in permanently. After a six weeks trial the Manager, Service User and any interested parties will meet to review the admission and make the move permanent if desired. Five Service User files were examined in detail and all contained assessments and contracts that included a statement of terms and conditions and were signed by the Service User. This home does not normally offer intermediate care. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of these standards were assessed during this Inspection. Quality in this outcome area is excellent. This judgment had been made using available evidence including a visit to this service. The Service User’s health and social needs are set out in an individual Care Plan and their health needs are fully met. Medication is appropriately stored and administered and Service Users feel that they are treated with respect and their rights are upheld. EVIDENCE: The Care Plans that are developed from the assessment and other information gathered and are comprehensive enough to enable staff to know and understand the Service Users health and emotional needs. The topics of mobility, weight, mental status, hobbies, religious observations, social interests and any special health needs are also discussed with the Service User. As well as monthly reviews by key workers, each Care Plan examined was reviewed and signed by the Service User to indicate that they had seen it and agreed with it. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 11 Care Plans include assessments on the Service User’s ability to manage their own personal care and records the support they need to enable them to retain independence as far as practical, particular preferences are also recorded for food, bathing, oral hygiene, hair and nail care etc. Risk assessments are carried out around issues such as mobility and falling, eating and maintaining a healthy weight range, skin integrity and individual risks such as diabetes, self-medicating and traveling independently. Risk assessments are reviewed monthly and are signed by the reviewing staff, normally the key worker. All the Residents are registered with the doctor of their choice and those that live close enough remain with their own doctor when they move in. Service Users are enabled to travel independently to doctor or hospital appointments if they wish and will be reminded of appointment in advance so plans can be made for early breakfasts and transport etc. Service Users have full access to specialist treatments, for example diabetic’s clinic and the district nurse and can request to see the doctor who visits the home regularly or will be advised to if staff have any concerns for their health. Records are kept of all appointments and treatment given. On examination the medication was found to be stored appropriately and the required policies and recording system was in place. There were no errors found. Service Users who want to manage their own medication are assessed by their doctor and sign an agreement to look after the medication properly, to store it safely and to take it as prescribed. Several of these agreements were seen on the Service Users files. They are reviewed annually or as circumstances change. Service Users who talked with the Inspector and those that completed the Commissions questionnaire all said they felt that their privacy and dignity is protected and felt that the staff were caring and genuinely concerned about their welfare. There is a public telephone for general use and Service Users can have a private line in their own room if they desire. Once a new resident has had a chance to settle in and have built up a relationship with the staff they are asked if they have any preferences around their death or treatment in serious illness. All the staff receive specialist training around caring for an ill or dying Resident and are prepared for the personal effects of caring for the terminally ill. The home endeavors to care for Service Users at home toward the end of their lives and will be supported by the district nurse and doctor to enable them to stay at home. Extra staff will be put on duty so that the Service User and their families can be properly looked after. Religious needs will also be addressed. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of these standards were inspected during this visit. Quality in this outcome area is excellent. This judgment had been made using available evidence including a visit to this service. This home put a lot of emphasis on encouraging Service Users to maintain contact with family and friends, to keep active and to take control of their dayto-day lives. The food offered is of a high standard and is generally enjoyed. EVIDENCE: A sample of the activities offered by the home includes, lunch out organised by the Hope Foundation and other meals out, a party at Eltham Collage, a quiz, music and movement sessions, name the doll competition, exercise and dancing, a cabaret and other entertainers, a BBQ with family and friends invited, classical music recitals, local walks, Eltham Collage music group, skittles and listening to music. After each activity the Service Users are asked to record their feelings about it and the comments were on the whole favourable. They are given the opportunity to opt out of taking part and on one occasion the Service Users voted to cancel the activity altogether as it was too hot. At the Christmas party staff put on a carol concert for the Residents and some wore saris. They were much admired by the Service Users and the outcome Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 13 was that they had a session when staff bought some saris into work for the Service Users to try on. The home has a small library and the Bromley Library bring a change of books, including large print ones, at regular intervals, they will also take orders for special requests from the Residents. The library doubles up as a visitor’s room and has tea-making facilities for the use of the Service Users and their visitors. Visits from family and friends are welcomed at all reasonable times and Residents are encouraged to continue to take part in social activities out of the home. One person still goes out to lunch with friends and another walks to her daughter’s home for Sunday lunch. Holidays are arranged and one Service User regally organises her annual holiday and still travels abroad. The dinning room is pleasantly arranged with tablecloths and flowers on the table. Each table has a menu with choice of meal and after they have eaten everyone is encouraged to comment on the meal on the back of the menu, these comments are reviewed by the Manager and chef who will take action if a meal was not thought to be of the usual standard. An alternative will be offered if requested and a meal will be saved for anyone out of the house for any reason, special diets are offered for those with religious or medical needs. When asked the Service Users felt the food was of a high standard and varied, all said they enjoyed their meals and one said the only complaint she had was that they were feed too well! Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of these three standards were examined on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Service Users can be confident that their complaints will be listened to and acted on. Residents are protected from Abuse and their legal rights are upheld. EVIDENCE: The home displays leaflets around the home telling Service Users about its complaints procedure and how to make a complaint, it includes the Commissions details. The complaint recording system is as required and a complaint can be clearly followed from start to conclusion. There have not been any complaints recorded since the last Inspection and the home give it’s Service Users ample opportunity to give comments about the quality of the service and records compliments as well as complaints. The commission has received a letter of concern from the London Ambulance Service. They had been called to the home to attend to a Service User who had fallen and needed medical assistance. The Ambulance Service felt that it took a long time for the door to be answered and as the front windows to the main lounge were wide open felt that the Service Users could be at risk of either wandering away from the building or of falling out of the window. They did comment however, that the Service User they had been called to assist appeared to be well cared for and well nourished so they had no concerns of the level of care given to the Service Users. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 15 The Manager was surprised by the concern raised but did remember the occasion. She told the Inspector that the Service User had been very distressed and was being supported by two staff members on the first floor and another had been collecting together belongings and the information the hospital would need if the Service User were admitted. Other staff were reassuring and seeing to the needs of the rest of the Service Users. So when the doorbell was rung there was no one in the office by the front door and it took a while for a staff member get from upstairs to the door. She apologised to the medics and was unaware that they had been unduly inconvenienced, as they did not raise the issue at the time. The windows were wide open as the weather had been unusually hot, all of the Service Users are mentally alert and none are likely to be in danger if they leave the building. All of the Service Users are registered to vote and are enabled and assisted to go to the polling station or to register for a postal vote if they wish. The Residents maintain control of their legal rights and the home will arrange for solicitors to visit if it is requested, if someone was to become unable to manage their own affairs the home would make arrangements with their family or the Manager would facilitate access to advocacy services. Service Users are protected from abuse by the homes recruitment policy that makes sure that no one with a history of abuse is allowed to work in the home. Training is given about adult protection and whistle blowing. Several staff files were examined and evidenced that the required checks and safeguards are undertaken. The Manager carries out spot checks and will come into the building without notice at any time of the day or night including weekends and bank holidays. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of these standards were examined during this visit. Quality in this outcome area is excellent. This judgment had been made using available evidence including a visit to this service. The Service Users live in a safe, well-maintained environment that is comfortable and homelike. EVIDENCE: Queen Elizabeth House is a safe and well-maintained environment; the home conforms to requirements from the local fire service and has it’s own maintenance man who oversees Health and Safety matters and appeared knowledgeable and keeps good, clear records of the checks he carries out. The communal areas are tastefully decorated and there are pictures, flowers and ornaments throughout the house. The furniture is comfortable and of a good quality. The garden is a pleasant area with ample seating and a pond, there is a small area that is set-aside for one of the Service Users to display her garden ornaments bought from home. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 17 There are sufficient lavatories and bathrooms that are equipped as necessary with specialist equipment. One of the bathrooms have been modernised with new fixtures and there are plans to rejuvenate the rest. Each bedroom is individual to the Resident and most have personal possessions, they are all furnished to requirement. If needed the rooms have specialist equipment to enable the Resident to maintain independence. Since the very hot weather a decision has been made to place water jugs and glass in each bedroom that are changed daily or replenished when needed. Several of the bedrooms have been decorated and refurbished and plans are in place to do more of the rooms. The home was very clean, hygienic and had no unpleasant odours. The home has been awarded the Gold Standard under the Clean Food Award, run by Bromley Council. The kitchen was clean and well managed and required records are kept and were examined. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The whole of this are was examined during this Inspection. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Service Users can be confident that their needs are met by the numbers and skill mix of staff, that they are in safe hands and staff are trained and competent to do their jobs. EVIDENCE: The rota shows that there are sufficient staff, care and utility, on duty to meet the needs of the Residents and the home has recruited more senior care staff since the last Inspection so that there are sufficient numbers to enable the Manager to rota a senior staff member to work at night so as to better monitor the service. Staff records inspected show that no one is allowed to take up post without the required checks and safeguards having been taken up and recorded. The home is located in a desirable residential area but this makes it difficult to attract and keep staff as it is not close to a town centre or on a regular bus route, the nearest buss stop is a good walk away and people travelling home after a late shift feel that it is too isolated and feel unsafe, staff often site this as a reason to leave. The Manager is seeking ways to recruit and retain staff from the local population; in the meantime she is looking further a-field for good quality staff. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 19 The Manager invites new candidates to visit the home to complete the application form to enable her to assess potential recruits and establish that they have the right credentials prior to interview. If the home uses Agency staff they try to use the same people from a small pool that have worked there before to aid the smooth running of the home, before a new agency worker is used the Agency is asked to complete a questionnaire to confirm the staff has the experience, qualifications and CRB clearance required. The training program and action plan is completed annually and is comprehensive and covers mandatory training as well as specialist topics needed to meet the needs of the Residents. Over 50 of the care staff hold qualifications of NVQ2 and above or an equivalent qualification. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of these standards have been assessed on this occasion. Quality in this outcome area is excellent. This judgment had been made using available evidence including a visit to this service. The home is well run and efficiently managed within an ethos of empowerment and respect. The Manager has set up exhaustive systems to check that the home is run in the best interests of the Service Users. The Resident’s rights and financial interests are safeguarded by the homes policies and procedures. The Health and safety of the Service Users and staff are promoted and protected. EVIDENCE: The office is well ordered and the Manager and staff on duty were able to provide information and paperwork requested quickly, all the files examined Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 21 were tidy and logically set out which made gathering information from them easy. The records and files are regularly reviewed and have been signed and dated as such. Residents that the Inspector has spoken to praised the manager and the way she worked, they said that she was caring and helpful. Staff spoke of her as having high standards that she insisted that they worked properly but that she was fair and would listen to their point of view. A Doctor who visits the home says it is “a well run home with good support and care staff, delivering a high quality of care.” And a member of a Care Management team says that “the Manager has always made herself available…., observations are very in-depth and she provides the relevant information for the reviews and communication (verbal and written) is good.” In discussions with the Manager it was obvious that she was committed to listening to the Service Users and to running the home in a way that would make them fell in control and part of the decision making process. They are constantly given opportunities to comment on how they feel the service is run, about the food and the daily activities. Quality Assurance Surveys are send to Service Users and their families annually and the information collected is collated and an action plan is devised to address areas that are found to be weak, The outcome of the survey is put into a graph format that is easy to understand and is displayed for all to see. The outcome of the most recent survey indicates that the Service Users and their families believe that the home is managed to a high standard and that they are happy with the service received. This was also the outcome of the surveys that the Commission sent to the Service Users, families and staff. Queen Elizabeth House has recently achieved the Investors in People award and held a party to celebrate the it. The home had plentiful supplies and gives the appearance of being a thriving business, it is part of the Greensleeves Homes Trust that runs 17 care homes and a financial statement is available. The trust has recently commissioned an independent company to carryout a quality assurance inspection throughout all of its services. Regular regulation 26 visits take place and a copy of the report is sent to the Commission. The home does not manage the Residents finances. Records show that regular supervision is given to staff and The Manager has had one of the Trusts Managers assigned to her to so that the same person, instead of several different people as in the past, gives her regular supervision now. She is pleased with this arrangement and says it aids continuity. Required policy and procedures are in place and the record keeping is detailed, relevant and stored in a manner that protects confidentiality. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 22 A random selection of Health and Safety records were inspected and found to be satisfactory. All of the required safety certificates are displayed on a notice board in the office they were all current. Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 4 3 4 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 4 3 3 3 3 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 3 3 3 4 4 Queen Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Elizabeth House DS0000006962.V309232.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 House DS0000006962.V309232.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!