Inspection on 26/07/05 for Queen Elizabeth House

This inspection was carried out on 26th July 2005.

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

Other inspections for this house

Queen Elizabeth House 25/10/06

Queen Elizabeth House 23/01/06

Queen Elizabeth House 08/02/05

Queen Elizabeth House 13/09/04

Queen Elizabeth House 12/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Spring Lane Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Queen Elizabeth House 38 Southborough Road Bickley Kent BR1 2E Lead Inspector Lorraine Pumford Unannounced 26 July 2005 10:00 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 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 G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth House Address 38 Southborough Road, Bickley, Kent, BR1 2EE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Greensleeves Homes Trust Miss 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 G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 08/02/05 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 G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by one inspector who was in the home for approximately 4 hours. During that time some service users and staff were spoken with privately and their views have been incorporated into this report. Some records were examined and parts of the premises inspected. All Registered Care Homes receive a minimum of two inspections within a 12 months period, as this inspection may not have covered all the “National Minimum Standard” on this occasion, should further information be required it is recommended that a copy of the last inspection report also be obtained. What the service does well: Prospective service users can be confident that a suitably qualified and competent person will assess their needs. Prior to their admission the home undertakes to provide the service user with a written undertaking stating the home will be able to meet their assessed needs at the time of admission. Service users are provided with a signed contract indicating both partys rights and responsibilities and terms and conditions of occupancy. Prospective service users are given the opportunity to visit the home prior to admission. Service users can be confident that staff will respect their privacy and dignity and they will be given opportunities to express their personal choice and preferences. Service users of provided with a varied nutritional diet and are given opportunities to participate in a variety of social activities. Service users are provided with information regarding the home’s complaints procedure and can be assured that any concerns they may have will be taken seriously by the home’s manager. Service users are provided with a clean comfortable environment suitably equipped and furnished. All bedrooms are single with ensuite facilities. There is an attractive well-maintained garden to the rear of the property. The manager ensures that a sufficient number of staff are employed to meet the service users’ needs and staff receive regular supervision and training. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 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 G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 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 standard(s) 2,3,4,5 Service users are provided with a contract, this provides a safeguard for both parties. The comprehensive assessment process ensures that service users will not be admitted to the home unless care staff are able to meet their needs. EVIDENCE: The manager or a senior member of staff visits service users in hospital or their own home to undertake an assessment of need prior to them being offered a place in the Queen Elizabeth House on a trial basis. The manager stated that service users and their representatives are encouraged to visit and spend time in the home before making a decision about moving into Queen Elizabeth House. All service users are provided with a contract detailing their terms and conditions of residency and both parties rights and responsibilities, a copy of the service users care plan completed by staff following the assessment is attached to the document indicating the organisations commitment to meeting the service users needs. The home does not provide intermediate care. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7,8,9,10 Care plans, which include individual risk assessments, provide staff with written guidance about service users’ needs. Service users’ privacy and dignity is respected. EVIDENCE: Records seen indicate a comprehensive care plan is developed following the initial assessment of service users needs. The manager stated that staff talk with service users and observe their mobility etc, during their initial visits to the home prior to admission; this information is then used to develop the individual care plan, which comes into operation at the time of admission to the home. Part of the document includes service users’ waterlow score to assess service users susceptibility to pressure areas, at present the document is left blank if a service user does not have a pressure area upon admission to the home. The manager was advised to record on the document none when this was the case. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 10 Service users spoken with stated staff frequently talk to them about their personal preferences in respect of personal care, the way they like personal possessions in their room to be displayed and their likes and dislikes. Service users spoken with stated staff respected their privacy when assisting with personal care. Service users are addressed by their preferred name. There was evidence that care plans are reviewed on a regular basis, the manager stated this was generally monthly. However in the event of a significant change in the service users health or circumstances, the care plan would be updated more regularly. Medication is appropriately stored in a locked trolley, which is secured to the wall. The manager confirmed that any staff responsible for administering medication have received appropriate training from suitably qualified and competent person. Where staff have handwritten entries to the MAR sheet it is advisable for the record to be signed by two members of staff to reduce the risk of error. The manager stated that when service users make a request to administer their own medication, a letter of authorisation is sought from their GP and a risk assessment is carried out in relation to the practice. The staff need to ensure that service users ability to manage the task is regularly reviewed and records kept to reflect this. The home’s policy relating to this issue was submitted following the inspection. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12,15 Social activities and meals are both well managed, creative and provide daily variation and interest to people living in the home. EVIDENCE: Since the last inspection, a full time activity coordinator has been appointed. Service users spoken with stated they enjoyed the variety of activities provided, and since the coordinator’s appointment, opportunities to go on outings to the coast and other local places of interest has increased. On the day of the inspection a guest was playing the piano for service users in the main lounge. The record of meals provided to service users indicates they are provided with a varied nutritious diet. Service users stated they were happy with the quality of food and are given a choice of alternatives if they did not like the option on the menu that day. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16,18 Service users can be confident that their concerns will be listened to, taken seriously and acted upon. Staff training takes place to protect vulnerable adults from any abuse. EVIDENCE: Service users are provided with information on the homes complaints procedure and how to contact the CSCI directly. The manager stated that any complaint received by the home would be recorded, including action to address the issues raised. At present complaints are recorded in a hard-backed book. Whilst there was no evidence to suggest information regarding complaints had been removed from the book, it was apparent that staff had removed pages and the document was starting to fall apart. Discussion took place regarding a more effective method of recording complaints received by the home. Service users spoken with stated that though they had not had cause to complain, however, felt confident that they could talk to the manager should they have any concerns. Staff spoken with stated that they had received adult protection training, including information regarding the homes whistle blowing policy and felt confident that they could go to the manager if there were concerned regarding colleagues care practices. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19,21,24,26 Service users are provided with a clean comfortable environment suitably equipped and furnished. EVIDENCE: On the day of the inspection all areas of the home were clean, tidy and free from unpleasant odours. Both the building and grounds are well maintained, the garden is wheelchair accessible and well laid out with seating areas for service users who wish to sit and enjoy the attractive garden. Service users accommodated at the home benefit from having a single bedroom with ensuite facilities. Service users stated they had been given the opportunity to bring in small personal items from home to personalise their bedrooms. Service users spoken with stated they liked their bedrooms and had everything they needed, that bedlinen was changed regularly and their bedrooms were regularly cleaned. Although baths in the home are fitted with appropriate hoists and positioned to enable staff to assist service users with bathing, the baths are domestic in style and colour and do not detract from a homelike environment. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 14 The laundry was clean and well organised, and service users were satisfied with the laundry service. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Suitably qualified and competent care staff are employed to meet the needs of service users. Staff are provided with appropriate training opportunities. The procedures for the recruitment of staff are robust and aim to protect service users living in home. EVIDENCE: The registered manager oversees the day-to-day running of the home between Monday and Friday. In her absence the home is managed by one of the senior care staff, additional staff are employed to undertake cooking, domestic tasks and administration. Staff responsible for cleaning and undertaking the laundry do not work at weekends. Care staff undertake these tasks in addition to care duties during this period of time. One member of staff in particular thought this increased the care staffs workload substantially. Discussion took place with the manager regarding this issue and that all staffing levels need to reflect the fact that service users reside in the home seven days a week and that their needs do not reduce over the weekend period. There is a staff rota indicating the names and hours of duty of all people working in the home. There is photographic ID for all members of care staff working in the home. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 16 Records indicated that comprehensive procedures are in place regarding the recruitment of staff to work in the home. There was evidence that staff had completed application forms and the manager had taken up a minimum of two references on all care staff working in the home. The Trust also ensures that each member of staff has a clear CRB check completed before they commence work. Staff spoken with stated that they have been provided with a job description and a contract of employment detailing their terms and conditions of employment. Staff stated that they had initially worked in the home as a supernumerary member of staff, shadowing a senior colleague until both parties felt confident they were competent and able to work independently. Staff spoken with stated they had completed NVQ 2 training courses and also undertaken statutory training courses such as a first aid, moving and handling, food hygiene and health and safety training. The Trust recognises members of staff who have completed relevant training courses by awarding them additional pay increments and ultimately possible progression to a higher post. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36 Procedures are in place to monitor and develop the quality of care and service provided in the home. Service users can be confident that staff receive appropriate supervision from senior staff to ensure good practice is maintained. EVIDENCE: Records indicate there are sound audits and quality assurance mechanisms in place. Questionnaires are regularly sent out to service users, relatives and stakeholders to ascertain peoples views in relation to the care and service at Queen Elizabeth House. This information is collated by the Trust and incorporated into the annual report The manager stated that she regularly undertakes an audit to monitor staff practice and to look at ways of improving the service provided. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 18 Care staff spoken with stated they receive regular supervision from a senior member of staff to monitor practice and personal development. The manager stated that she receives supervision from one of four possible members of the Trust. The inspector expressed concerns that this could lead to a lack of consistency, or confusion with different management styles, further whoever undertakes the responsibility of supervisor must have received appropriate training to undertake the task. The manager stated she feels supported by her employer and did not share the inspectors concerns regarding this method of supervision. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x x Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 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. 1. 2. Refer to Standard 9 16 Good Practice Recommendations Clear evidence needs to be kept that service users ability to self medicate is monitored and reviewed by staff. The current book used for recording complaints is replaced, and the new system includes an index of complaints received and the action taken by staff to address them. Staff are instructed not to remove pages from this document. Queen Elizabeth House G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 G51-G01 s6962 Queen Elizabeth Hse UI v240247 260705 Stage 4.doc Version 1.40 Page 22 - 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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