Inspection on 13/12/05 for Queen Elizabeth Park

This inspection was carried out on 13th December 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 Park 05/11/07

Queen Elizabeth Park 27/06/06

Queen Elizabeth Park 23/11/04

Queen Elizabeth Park 24/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Queen Elizabeth Park 1-72 Hallowes Close Guildford Surrey GU2 9LL Lead Inspector Sarah Radlett Announced Inspection 13th December 2005 09:30 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 Park DS0000054733.V262548.R01.S.doc Version 5.0 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 Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth Park Address 1-72 Hallowes Close Guildford Surrey GU2 9LL 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) 01483 531133 info@qepcarehome.fsnet.co.uk CareBase (Guildford) Ltd Katarina Parr Care Home 77 Category(ies) of Dementia (26), Old age, not falling within any registration, with number other category (51) of places Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2005 Brief Description of the Service: Queen Elizabeth Park is a new purpose built care home registered to provide care for up to 77 older people, including the care of 26 Service Users with dementia, 26 with nursing needs and 25 requiring residential type care. The home is divided into three units and the accommodation is set out on three floors. All rooms are single occupancy with en-suite facilities. The home is situated in a residential are of Guildford. There is a garden to the rear and the side of the property and there are adequate parking facilities within the grounds. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours and was the second inspection carried out by the Commission for Social Care Inspection for the year 2005-2006. Sarah Radlett, Regulation Inspector, and Geraldine Yates, Specialist Pharmacist Inspector, carried out the inspection. The Registered Manager, Ms Katarina Parr was present throughout the inspection. The inspectors also spent time with the staff on the three units. As part of the inspection process the Registered Manager was required to complete a pre-inspection questionnaire and comment cards were distributed to Service Users, relatives and various visiting health care professionals. A partial tour of the premises took place and various written records were examined, including nine care plans and service user assessments, staff recruitment files, staff training records, staff duty rotas, samples of policies and procedures, and a sample of the medication administration records. The inspectors spoke to Service Users, visitors and some of the staff on duty at the time of the inspection. The Inspectors would like to thank the staff and Service Users for their time, assistance, and hospitality during the inspection. What the service does well: The Service Users appeared well cared for and were dressed appropriately. Service Users spoken to stated that they were happy with their accommodation and liked the home. Care was provided in a dignified, respectful manner. All Service Users spoken to made positive comments regarding the staff, including; ‘staff are kind, good and friendly’, ‘they really do care’. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 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 Park DS0000054733.V262548.R01.S.doc Version 5.0 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 Park DS0000054733.V262548.R01.S.doc Version 5.0 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): 3, 4, 5 & 6 A full assessment of Service Users needs is carried out prior to their admission, however one Service User did not have any documented evidence of this assessment. Prospective Service Users are able to visit the home prior to their admission. EVIDENCE: A full assessment of Service Users needs is carried out prior to admission to ensure that the home can meet their needs. Samples of the Service Users assessments were seen and found to be comprehensive. Of the files examined, one permanent Service User, who had previously been at the home for respite care did not have an up to date pre-admission assessment. There was therefore no documented evidence that the Service Users needs had not changed since their respite admission more than a year previously. Prospective Service Users and their relatives are able to visit the home prior to their admission. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 9 Intermediate care was not provided at the home. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 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): 7, 8, 9 & 10 Comprehensive care plans were in place which set out the Service Users health, personal and social needs. Risk assessments were in place; however some omissions were noted in the record keeping. A review of medication handling was undertaken by a CSCI pharmacist inspector who found that the home has significantly improved their procedures for administering and recording medication and could demonstrate safe practices. Care was provided in a caring, dignified and respectful manner. EVIDENCE: Nine care plans and Service User assessments were randomly selected for inspection. The care plans set out in detail the action that needed to be taken to meet the assessed needs. There was evidence of regular review. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 11 Samples of risk assessments were inspected. Some of the records sampled contained omissions; specifically; the Services Users name, a signature of the staff member who carried out the assessment or a date on which the assessment was completed. All Service Users were registered with a local GP. Service users had access to visits from a variety of other health care professional services including physiotherapist and chiropodist. Medication stocks and records were sampled and showed that service users were receiving their medication as intended by their doctors. A small number of service users held and administered some of their own medicines but most had medication administered by either registered nurses or designated trained care staff. The risks of service users holding their own medicines had been assessed for all but one person who only kept a low risk cream. The manager was advised to assess the risks associated with this activity, especially the risks to other service users. One service user was prescribed a night sedative medication to be given ‘as needed’ with no clear guidelines as to what constituted needed. Clear records were kept of all medication received into the home, administered to service users and returned to the pharmacy for disposal and all medication was stored securely for the protection of service users. Staff were observed to carry out their care duties in an appropriate manner and to respect the service users privacy and to treat them with dignity. Service Users spoken with were complimentary regarding the staff and the care given. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 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): 14 & 15 Service Users are encouraged to make choices. The provision of food within the home was met with mixed comments from the Service Users. EVIDENCE: Service users are encouraged to personalise their rooms, evidence of this was seen on the day of the inspection. Staff were observed to give the service users appropriate choice. The quality of the food within the home was met with very mixed feelings from the Service Users and visitors spoken to during the inspection. Comments made ranged from ‘the food is very good and I look forward to my dinner’ to ‘the food is atrocious, how do they expect us to eat it?’ This mixed feeling was also evident in the comment cards received prior to the inspection. Menus were seen and it appeared that Service Users are offered a varied and nutritious diet. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 13 Service Users on two of the three units were observed to eat lunch during the inspection; the food was presented in an appealing manner and was again met with very mixed comments from Service Users. The Registered Manager stated that the home was aware of some of the negative comments regarding the food and that a Service User satisfaction survey had been recently completed. The results of the survey indicated that approximately 70 of Service Users were happy with the quality and quantity of the food. The Registered Provider had arranged for a food consultant to visit the home and was currently reviewing some of the recommendations made, but stated that there were nothing specific that needed improvement. One of the Service Users spoken stated that she did not feel that her concerns regarding the food had been taken seriously and that there was ‘little point saying anything as no one listened anyway’. This was discussed with the Registered Manager and it was felt that the home might not be able to meet this Service Users expectations. It is strongly recommended that the Registered Manager spends time talking to this Service User regarding the food and keeps the Commission for Social Care Inspection informed of the outcome. It is required that the Registered Manager addresses the Service Users satisfaction with the quality of the food and provides an action plan as to how the overall Service User satisfaction will be improved. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 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): 16 The complaints procedure was available to all Service Users. EVIDENCE: A copy of the homes complaints procedure was contained within the Service Users Guide, which was accessible to all Service Users. Service Users spoken to stated that they were aware of how to raise any concerns and complaints. They stated that they felt the staff were approachable and in the majority of cases they felt that their concerns and complaints would be listened to and acted upon. The homes complaints log was not examined at this inspection. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 15 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): 19 & 26 The home was suitable in layout for its purpose. The home was found to be accessible, safe and well maintained with a pleasant atmosphere. EVIDENCE: The inspectors toured areas of the home. It was seen to be warm, bright and well maintained. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 16 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): 27, 28, 29 & 30 The staffing arrangements in place on the day of the inspection were sufficient to meet the needs of the Service Users; however there is continued concern regarding the homes night time staffing numbers. Service Users were protected by the homes recruitment procedures. EVIDENCE: The staff rotas of the three units were inspected. They demonstrated that the skill mix was appropriate to meet the assessed needs of the Service Users living in the home. At the previous inspection it was felt that the night time staffing numbers, one trained nurse and one carer, in the nursing unit were insufficient to meet the Service Users needs. The home now operates a system where a carer from the residential unit assists on the nursing floor between 4 and 6 am. There is concern that this staffing arrangement leaves only one staff member on the residential unit during this time. Discussion with the staff on the nursing unit evidenced that the quality of night time care could be improved by increasing the staffing numbers. All Service Users have recently had an updated continence assessment by the continence advisor nurse. The head of care for the nursing unit feels that with another staff member at night she could introduce a programme to reduce night time incontinence; thus improving the Service Users quality of life. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 17 It is required that the Registered Manager completes a risk assessment detailing if there are any potential risks to the Service Users in the residential unit by only having one staff member between 4 and 6 am. The strong recommendation that the staffing levels on the nursing unit are reviewed to ensure that at all times there are adequate staff on duty throughout the home to meet the needs of the Service Users made at the previous inspection has been repeated. The home is committed to NVQ training, some staff members are NVQ assessors and the home will start their own in-house training in January. Samples of staff files were examined at inspection and found to be clearly set out and contain all the required information. Samples of the staff training files were seen. Trained staff have received first aid training, ensuring that a qualified first aider is on duty at all times. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 18 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): 37 & 38 Shortfalls were found in some of the documentation within the home Policies and procedures were in place to ensure, so far as is reasonably practicable, the health, safety and welfare of service users and staff. EVIDENCE: A sample of the records within the home were inspected and some shortfalls were found in the care plan and assessment documentation – details of which are recorded under standards 7 and 8. Required health and safety training had taken place. Required servicing certificates had been previously inspected and seen to be in order to ensure so far as is reasonably practicable, the health, safety and welfare of service users and staff. Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 3 Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 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 OP3 Regulation 14 (1)(2) Requirement The Registered Manager must ensure that all new Service Users have a pre-admission assessment. The Registered Manager must ensure that all care plans and risk assessments are fully completed. The Registered Manager must ensure that a documented risk assessment is in place for all service users who hold and administer any of their own medicines. The Registered Manager must address the Service Users satisfaction with the quality of the food and provide CSCI with an action plan as to how the overall Service User satisfaction will be improved. The Registered Manager must ensure that a risk assessment is completed detailing any potential risks to the Service Users in the residential unit by one having one staff member between 4 and 6 am. Timescale for action 13/12/05 2 OP8 15 (1)(2) 13/01/06 3 OP9 13 (4)(b) 13/01/06 4 OP15 16(2)(i) 24 (1)(2)(3) 13/03/06 5 OP27 12 (1) 13 (4)(c) 13/01/06 Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It is strongly recommended that the Registered Manager produces a clear care plan for each service user who is prescribed medication ‘to be given as needed’, to provide detailed instructions to staff as to when to give the medication. This will ensure that medication is administered in a clear and consistent way for the benefit of Service Users. It is strongly recommended that the Registered Manager spends time talking to a specific Service User regarding their complaints about the food and keeps the Commission for Social Care Inspection informed of the outcome. It is strongly recommended that the Registered Manager reviews the staffing levels on the nursing unit to ensure that at all times there are adequate staff on duty throughout the home to meet the needs of the Service Users. 2 OP15 3 OP27 Queen Elizabeth Park DS0000054733.V262548.R01.S.doc Version 5.0 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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