Inspection on 17/05/05 for Queen Margaret`s Nursing Home

This inspection was carried out on 17th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Queen Margaret`s Nursing Home 24/10/07

Queen Margaret`s Nursing Home 15/11/06

Queen Margaret`s Nursing Home 02/11/05

Queen Margaret`s Nursing Home 09/12/04

Queen Margaret`s Nursing Home 13/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Queen Margarets Nursing Home 19 Filey Road Scarborough North Yorkshire YO11 2SE Lead Inspector Anne Prankitt Unannounced 17th May 2005 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 Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Queen Margarets Nursing Home Address 19 Filey Road Scarborough North Yorkshire YO11 2SE 01723 353884 01723 350082 info@queenmargarets.co.uk Mrs Ann Christine Davey t/a Hawkfish Limited 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) Mrs Colleen Coral Moore Care home with nursing 44 Category(ies) of OP Old age (44) registration, with number TI Terminally ill (4) of places PD Physical disability (1) Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The category of registration PD, relates solely to one identified service user and registration will be amended to remove this category at such time as the identified service user is no longer accommodated in the home. The registered persons must advise the Commission when this occcurs. 2 The bathroom currently located in room 25 must be re-located to a more suitable site on the same floor within eighteen months of registration. 3 Room 44 will cease to be used as a bedroom as soon as vacated by the service user curently occupying the room. 4 All service users` bedrooms must be equipped with a lockable facility, and bedroom doors must be fitted with suitable locks within eighteen months. 5 Rooms 30, 31,32,38,39 and 40 must be occupied only by service users whose assessed needs are that they would not be adversely affected by being unable to see out of the window when seated. Date of last inspection 9th December 2004 Brief Description of the Service: Queen Margarets Nursing Home is a care home providing nursing care, personal care and accommodation for up to 44 older people. Hawkfish Limited owns the home. The home is located on the south side of Scarborough, close to shops, the post office and a main bus route. The home was originally registered as a nursing home in 1985, and purchased by the current owners in March 2003. Queen Margarets is a large detached Victorian redbrick built house. It has a basement plus four floors. These are serviced by two passenger lifts. There are 41 rooms in total. All rooms have a wash hand basin. 27 rooms have a full en suite facility. There is a garden area to the front and side of the property and this is accessible to the service users. There is also a car park. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 8 hours, and was undertaken by two inspectors, Mrs Anne Prankitt and Mr David Blackburn, with a previous half days preparation having taken place prior to the inspection. The registered manager, Mrs Coral Moore, was available throughout the course of the day. Mr and Mrs Davey, the registered persons, also contributed during the inspection. A tour of the premises was completed, which included both private and communal areas. Two visitors and also a number of staff were spoken to. In addition to this, time was spent speaking with service users, and also observing the general activity in the home. Some records were inspected, including care plans of service users identified at the time of the inspection. The inspection concluded with a feedback session, involving Coral Moore, Registered Manager, Val Codling, Deputy Manager, and David Blackburn and Anne Prankitt, Regulatory Inspectors. What the service does well: The residents are cared for in a clean, warm and friendly environment. The staff who work at the home receive training to help them provide good care. The manager, who is now registered with the Commission for Social Care Inspection, approaches her role within the home seriously, and the care staff said that they feel well supported by the trained staff team, and also by the owners of the home. Comments from residents about the staff included that ‘they’re lovely’, ‘we’re well looked after’, and ‘you can have a bit of fun with them’. Staff comments included that they are ‘happy with the management’, that they feel ‘very supported’, and that if they had any concerns they ‘could go in confidence’ to the management. One staff member concluded about the owners that they ‘can’t believe how they have turned the home around’. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 6 Comments from the residents about the food were positive, and included that ‘the food is excellent. I get exactly what I want’, and that ‘there is always an alternative’. What has improved since the last inspection? What they could do better: Improvements to the building have been made, and further improvements are planned. Those matters highlighted at this inspection as needing to be prioritised included the cleaning of mechanical fans, the painting of the laundry, and consulting with the fire officer about a fire arrangement at the home. The registered manager has been asked to reassess two risk assessments relating to the safe use of bed rails, and to ensure that staff do not secondary dispense medication. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 7 The staffing levels need to be improved upon. The registered persons are currently seeking to improve these through active recruitment. Whilst the registered persons have worked hard in ensuring that Criminal Records Bureau checks have been completed for existing staff, they now need to ensure that, without exception, all new staff have a Criminal Records Bureau enhanced check completed by them and prior to deployment. 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 Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 8 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 Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 9 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) 3 Sufficient information is gathered prior to admission in order that the home can make an informed decision that the needs of prospective service users can be met. EVIDENCE: The registered manager ensures that pre admission assessment is carried out for prospective service users, before a decision is made that their needs can be met. The pre admission assessments seen included information provided by the hospital, care management care plans and the Primary Care Trust. The staff use this information in order to develop care plans at the home. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 Service users are enabled access to health services, and staff are provided with good information from which care can be delivered. The medication systems at the home are good, and are well audited. However, staff practice regarding the disposal of medicines must be improved upon. Service users are treated with dignity and respect. EVIDENCE: There has been continued improvement made to the care plans, and the information they provide staff about the holistic care that is needed by individual service users. The care plans are reviewed at least monthly. The manager is currently exploring ways in which service users and/or their representatives can be involved in the drawing up of the care plans. It remains a recommendation that they are signed as agreed wherever possible. One relative confirmed that they had been shown the care plan of their relative more than once. Advice is sought from the relevant professional where issues of concern about the health of service users arise, and there was good information recorded Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 11 within the care plans to support this. There was equipment available for the management of tissue viability, and also for safe moving and handling. Risk assessments have been completed, and include written guidance for staff to follow at various stages of the assessment. The medication system is well managed, and the registered manager carries out regular ‘on the spot’ audits of the system. There is a clear record of medication received from and returned to pharmacy. Those controlled drugs stored on behalf of service users could be reconciled with records kept. The controlled drugs register has now been amended to include the strength and dosage of medication prescribed. The registered manager has made the decision that homely remedies will not be used. Within the medicine trolley there was a tablet decanted into a pot. The staff member was unsure as to why it was there. Staff must ensure that they destroy any medication which has not been administered, and record on the Medication Administration Record the reason why. There is a fridge available for the storage of medicines that need to be kept cool. Record needs to be kept on a daily basis of the temperature of the fridge. However, all those recordings kept, evidenced that the fridge was kept at an appropriate temperature for those medications stored. Staff spoke to service users with respect, and personal care was given in private. Service users spoke positively about the care that staff provided, and comments from one relative included that standards have improved since the new owners took over the home, and that they feel confident that there is someone at the home who knows their relation. One member of staff said that they had just received a supervision session, which focussed on ‘dignity’. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 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 standard(s) 13 Unrestricted visiting arrangements results in service users maintaining good links with family and friends. EVIDENCE: Service users’ and relatives’ comments were unanimous in that visitors are welcomed into the home, and one relative gave an example whereby the home had made a special effort for their family following a bereavement. The visitor said that they are able to come and go as they wish, and that the staff keep in touch about any matters concerning their relative. A monthly newsletter produced by the registered manager informs service users and their visitors about forthcoming events at the home. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 13 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 and 18 Complaints made to the home are dealt with. The arrangements for dealing with matters of abuse at the home have been reviewed, and the policy updated to provide better protection for service users, and staff are clear about their responsibilities. EVIDENCE: The complaints procedure displayed in the foyer of the home has been amended, and now explains that a complaint can be made to the Commission for Social Care Inspection at any stage, should the complainant wish to do so. Since the last inspection, there have been two complaints made direct to the home. There is a clear record of the investigation following the complaint, and of the outcome. There have been no complaints made to the Commission for Social Care Inspection. One relative spoken with stated that they would be happy to take any concerns to the registered manager. In addition to this, the registered manager explained that the responsible individual holds a regular tea afternoon, when they mix with service users and relatives, who are able to pass on their comments. Staff spoken to said that they would report any matters of alleged or suspected abuse, and the homes policy has been amended to correctly state that any such issues would be referred to the local authority for investigation. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 14 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) 19,24 and 26 Continued investment has resulted in further improvements to the environment, which provides comfortable surroundings for those living at the home. EVIDENCE: Queen Margaret’s is a large imposing building situated on a main road into Scarborough. A former hotel, it has been adapted and upgraded to provide accommodation for a maximum of 44 residents. The building appeared in a good structural order internally and externally. Evidence was seen of improvements to the external structure, for example a new pitched roof and new covering to the flat roofs. The home is located on a main public transport route and provides easy access to local facilities and amenities and to the town centre. Internally improvements have been and continue to be made, for example new wet floor showers. A handyman is employed to ensure that matters of routine maintenance are attended to promptly and without delay. Fixtures, fittings, furnishings and fabrics in those areas seen were of a good Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 15 quality and in a serviceable condition. The works required to be carried out under the conditions of registration and following the requirements made at the last inspection had been or were being addressed. A report on an assessment of the premises and facilities undertaken by an occupational therapist was seen. Satisfaction reports were seen from the Environmental Health Officer and Fire Officer. A visitor said “I have noticed a number of improvements since the new owners took over.” A number of bedrooms were seen. Extensive work had been carried out in the redecoration, refurbishment and re-carpeting of some of the rooms. The registered providers stated that all rooms would be redecorated and recarpeted as time and occupation allowed. Most rooms were of a good size and generally contained the required furniture and furnishings. Some rooms had specialist equipment required for the proper care of that particular resident. Many rooms had an en-suite facility including some with bathing facilities. All bedroom doors could be locked. The rooms seen had been provided with a lockable drawer for the safe storage of personal items. A number of minor matters were referred to the registered providers for attention, for example, attention to carpets. The registered providers produced a list of maintenance matters to be addressed in the near future that covered all matters raised. Residents were complimentary towards the work carried out by the registered providers in the refurbishment of their rooms. “It’s a lovely room. I’m very pleased with it especially since they redecorated and put in a new carpet.” “I have a nice room and the views are wonderful.” The premises were clean, tidy, warm and free from offensive odour. Good attention was being paid to the maintenance of a pleasant and comfortable environment for residents. It was found however that a number of mechanical ventilation fans were in need of cleaning. The laundry was sited on the lower ground floor. It consisted of a washing area and separate drying and storage area. Industrial machines had been provided. The laundry assistant was well able to describe the procedures for the proper laundering of bedding, towels, linen and personal clothing. She was well aware of the good practice requirements around the promotion of infection control and the need for vigilance about the risks of cross contamination. Observation showed that the procedures described were being followed. The laundry areas required redecoration. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 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 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, 28 and 29 Whilst staff morale is good, the current staffing levels impact on the amount of time that staff are able to spend with service users. Staff receive training to assist them in meeting the needs of service users successfully. The registered manager has a good understanding of their responsibilities with regard to the recruitment of staff, and the areas where systems must be made more robust with regard to the recruitment procedure to ensure that service users are protected from risk. EVIDENCE: The registered manager was aware that the minimum staffing requirements for the home are not being met over the twenty four hour period. The registered providers are making arrangements to employ overseas staff in order that minimum staffing levels can be restored. Some comments received from service users included that, ‘staff are good but very busy. I sometimes think they have forgotten about me’. ‘I’ve noticed that recently staff don’t have the time, sometimes I have to wait a long time before anybody comes’. Staff comments included that they ‘have to be a bit quicker when staffing is low’, but that the team works well together. However, one staff member thought that there were sufficient staff. Of the 23 care staff currently employed, four had achieved a National Vocational Qualification to at least level 2. Six other staff were working the Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 17 award, some with only one or two units left to complete. The home is registered to care for up to four people who are terminally ill. The registered manager explained that four care staff are currently attending a palliative care course, to compliment the training already completed by two trained members of staff. The responsible individual and two trained members of staff were due to attend an infection control update, and the registered manager keeps up to date with current trends via the local nursing forum meetings. The files of the last two staff members to be employed were examined. They contained an application form, two written references, a POVA/First check, a training record/plan and a copy of the contract (terms and conditions of employment). An enhanced disclosure from the Criminal Records Bureau (CRB) had been received for one of the staff. The second was awaited. The last staff member to be employed was interviewed. She confirmed her starting date and that information had been provided for her CRB check. The registered manager stated that the contract was being revised and updated. New copies would be given to all staff. Copies of CRB disclosures were seen for all staff. All but one had been obtained by the present manager through their “umbrella body.” It is essential that the registered persons obtain a current CRB for all employees. CRB disclosures are not transferable from one employer to another. A third staff file was examined. The file contained only one reference, and there was no evidence available to confirm that this had been followed up. The registered manager stated that a second reference had since been requested, but had not yet been received. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 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 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) 31,33 and 38 The registered providers and manager have a clear and ongoing development plan for the home, which is understood by staff, and appreciated by service users and their representatives. The home is managed in such a way that the health and safety of service users and staff is considered. EVIDENCE: Since the last inspection, the manager has been successful in their application to become registered manager of the home. Staff, service users and a relative spoke positively about the contribution that they have made to the home. Staff who wished to elaborate stated that the home was a nice place to work, and that they were happy with the management, who supported them on a day to day basis, and also through regular supervision. One member of staff stated that they couldn’t believe how the management had ‘turned the home around’. Another stated that the manager was ‘doing a fab job’. The registered manager Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 19 is currently undertaking their registered managers award, and has completed four units. The registered manager provided evidence of completed questionnaires distributed among residents. These had been undertaken on a monthly basis and sought residents’ views on a number of general issues in the home. In discussion it was suggested that surveys now be carried out with a specific focus, for example food or activities. An analysis of the findings should be made and the appropriate actions taken to meet residents’ wishes. It was also recommended that the views of families should be sought on the services and facilities provided in the home. Policies and procedures were in place for the safe maintenance of the premises and to ensure the safety of residents, visitors and staff. Some of the qualified staff were moving and handling facilitators. Members of the care staff confirmed they had received training in moving and handling, first aid and fire safety. The relevant staff had a food hygiene certificate. Hazardous substances were safely stored in locked areas. Hot water temperatures were regulated. Tests at a number of outlets found the hot water temperature to be around 43° Centigrade. Thermometers were in place in each bathroom. Temperatures were being recorded. A survey on the risk from Legionella had been undertaken and was seen. Radiators were guarded. Windows, where required, had the necessary restrictors in place. Fire doors had been upgraded to meet the latest standard, new fire fighting equipment, for example extinguishers, had been provided. The registered providers and the handyman stated that the fire detection system was to be upgraded in the very near future. New door guards had been provided so that fire doors could be kept open in a legitimate manner. A new fire escape was in place together with new emergency lighting to this area. Proper attention was being given to matters of health and safety during the major refurbishment of the kitchen. A number of certificates and reports relating to the safety of the premises were seen. The matter of bedroom windows opening on to the fire escape must be addressed. The risk assessment for two service users discussed at the time of the inspection with regard to the use of bed rails was not wholly effective, and the accident book recorded incidents which had occurred as a result. In the case of one service user, the registered manager intended to explore the reasons why the bed rails were fitted following admission from hospital. In the second case, where the registered manager had been very proactive in making referral to the GP, continuing care, and care manager, it was agreed that a multi disciplinary assessment may produce more satisfactory results. Verbal feedback has been received that this has already been organised. Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 20 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 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x 1 x 1 STAFFING Standard No Score 27 1 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 2 x x x x 1 Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 21 YES 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 9 Regulation 13 Requirement Medication must not be secondary dispensed The temperature of the medicines refrigerator must be checked and recorded on a daily basis when in use All the minor matters of maintenance identified on the day of the inspection and noted in the report produced by the registered persons must be addressed and resolved within the timescale set Mechanical fans must be cleaned and kept clean The laundry must be redecorated including painting of the walls and floor In the absence of a renegotiated and agreed staffing proposal, the registered person must adhere to the minimum requirements of the staffing notice issued to the home by the Health Authority The registered person must apply for a Criminal Records Bureau check for all current staff for whom a disclosure has not been obtained by them Timescale for action 17 May and maintained thereafter 2. 24 16,23 31 August 2005 3. 26 23 30 June 2005 4. 27 18 17 May 2005 5. 29 19 Schedule 2 31 May 2005 for the remaining employee Page 22 Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 6. 29 19 7. 38 13,23 8. 38 13 (timescale of 09.12.04 not met) The registered person must ensure that two written references are obtained prior to the employment of staff, and any irregularities followed up prior to deployment The registered person must consult with the fire officer about the bedroom windows which open directly onto the fire escape The registered manager must refer for advice the service user identified at the time of the inspection to the multi disciplinary team with regard to the use of bed rails, and must review the risk assessment at the home immediately The registered manager must ascertain the reason why bed rails are required, and have been fitted, in the case of the service user recently admitted from hospital and then maintained thereafter 17 May 2005 and maintained thereafter 30 June 2005 17 May 2005 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. 3. 4. Refer to Standard 7 28 31 33 Good Practice Recommendations It is recommended that the care plans are signed as agreed by the service user and/or their representative The registered providers are reminded of the need for 50 of the care staff to have achieved a National Vocational Qualification in care to at least level 2 by 2005 It is recommended that the manager achieves accreditation at NVQ Level 4 or equivalent in management by 2005 Residents’ views on specific matters within the home, for J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 23 Queen Margarets Nursing Home example food should be sought formally The views of relatives should be formally sought on the care, services and facilities provided in the home Queen Margarets Nursing Home J53- J04 S40909 Queen Margarets Nursing Home V223940 180505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit 4, Triune Court Monks Cross YORK YO32 9GZ 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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