Inspection on 02/05/05 for Queen Mary House

This inspection was carried out on 2nd May 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 Mary House 14/11/06

Queen Mary House 29/11/05

Queen Mary House 02/09/04

Queen Mary House 27/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Queen Mary House Manor Park Road Chislehurst Kent BR7 5PY Lead Inspector Sue Meaker Unannounced 02 May 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 Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Queen Mary House Address Manor Park Road Chislehurst Kent BR7 5PY 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) 020 8467 3112 School Mistresses and Govenors Benevolent Institution Susan Perry CRH 36 Category(ies) of OP 36 registration, with number of places Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd September 2004 Brief Description of the Service: Queen Mary House is a large, detached three storey, purpose built home. The home is situated in a quiet residential area in Chislehurst in the London Borough of Bromley. The home is close to open woodland and Chislehurst common, and within walking distance of local shops and public transport. The home is administered by the Schoolmistresses and Governesses Benevolent Institution, a charity founded in 1843 and incorporated by Royal Charter, the home provides spacious accommodation in pleasant surroundings, for retired ladies from these and comparable professions. The home is surrounded by well maintained gardens which are easily accessible to the service users. Bedrooms are on two floors accessed by a passenger lift, benfitting from central heating, the temperature of which can be individually controlled by the service users. There are hand and grab rails on the stairs, in passageways, toilets, showers and bathrooms. Specialised bathing and toilet equipment and moving aids are readily available; all toilets, showers, bathrooms and bedrooms can be accessed from the outside in case of an emergency. There is easy access to a telephone and the majority of service users have their own telephone in their rooms. There is an emergency call system in all areas of the home used by the service users; and members of staff are on hand at all times to assist the service users as required. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a statutory unannounced inspection of Queen Mary House, a residential home administered by the Schoolmistresses and Governesses Benevolent Institution who are a charity. The inspection took place over seven hours, a tour of the premises took place and staff, care, medication, training and health and safety records were inspected. Lunch was also observed. Conversations took place with ten of the thirty two service users along with three relatives, all of whom viewed the care provision in the home in a favourable light and who said that they had no complaints about the home. The manager and staff were also positive about the home and commented favourably about the support and encouragement received from management, and the terms and conditions of their employment. What the service does well: Queen Mary House provides a safe and secure environment for its service users, the home is spacious and comfortable, well decorated and furnished to a high standard creating a home from home atmosphere clearly appreciated by the service users. The home benefits from good management; that is efficient and effective. The service users are well cared for and were happy to share their views about the good quality of care they receive. The home has a good recruitment and selection procedures, the training provided by the home is of a high quality and the home manager has been able to access specialist training enabling staff to update their skills and competence. The home has a very good activities programme and provides many facilities for the service users, including musical entertainment, hairdressing, access to the home’s library with an extensive choice of books. Functions are also arranged and service users said they were looking forward to the summer tea party planned for July. The home has a varied menu and service users said that they enjoyed the meals and that they were given a choice of what they wanted to eat and that their preferences were taken into account. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 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 Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 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 Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 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) 1,2,3,4 and 5 Service users and their families are provide with comprehensive information about the home; enabling them the make an informed choice as to whether the home can meet their assessed care needs. EVIDENCE: The home had a comprehensive statement of purpose available to service users; the home also had a brochure, that is in the process of being updated. The service user guide gives information relating to living in the home including the services and facilities provided and the complaints procedure, the service users had a copy of this document in their rooms. All service users had a contract with the home detailing the terms and conditions of their accommodation and care provision. The home manager carried out a pre admission assessment for all service users prior to them coming into the home; the home manger visited the prospective service user in their own home or in hospital to undertake this assessment. It was evident from speaking to the service users that their wishes are considered during the initial assessment. If the service user has any specialist needs these are identified and protocols put in place to meet Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 9 these needs; these services are then accessed via the service users GP; the home is able to provide the services of an optician, dentist and chiropodist. Prospective service users were invited to visit the home with their family/friends if they wished, they could stay for a meal enabling them to meet the other residents and members of management and staff. An initial trial visit was also offered thus enabling the service user to decide if the home is the right place for them and whether or not the home can meet their assessed needs. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.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) 7,8,9,10 and 11 Comprehensive care planning systems ensure that the health, personal and social needs of the service users are clearly defined ensuring that the staff have the information needed to satisfactorily meet service user needs, promoting and protecting their privacy, dignity and independence. EVIDENCE: Five care plans were looked at in detail, it was evident that the care plans had been formulated from the initial assessment. The care plans detailed the actions needed to deliver the care to the individual taking into account the service users wishes and preferences. There was evidence to support that the care plans were evaluated daily and reviewed on a monthly basis; service users spoken to confirmed that they were involved in this process and that their wishes were considered. All service users were registered with the GP of their choice and therefore have access to all primary care services. The District Nurses regularly visit the home and provide treatment for service users particularly around pressure sore care, continence and diabetes. The care plans seen specified treatment and preventative measures in place for service users and it was evident that health care needs were met by comprehensive recording in the care plan. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 11 All medication was securely stored; the home uses the “Nomad” system where the pharmacist fills a dosette box to the individual service users requirements. All medication was clearly identified on the medication administration record, however all medication not computer generated by the pharmacy should be written on the MARS sheet and labels should not be used. Staff, trained to administer medication, recorded and signed when medication was given; it was evident from the records seen that this was being done correctly. It was demonstrated, during a tour of the home, that staff were aware of the importance of speaking to the service users respectfully ensuring that their privacy and dignity was respected at all times; service users spoken to confirmed that the staff were sensitive to their needs, wishes and preferences. Service users spoken to said that their visitors were always made welcome by the home and that they were invited to functions and could also join them for a meal. The management and staff of the home were sensitive to the needs of the service users in the event of their death and had protocols in place to monitor the care of a terminally ill service user; it was evident that service users and their families were sensitively treated and that their wishes were respected, it was the policy of the home to maintain the service user in their own room. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.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) 12,13,14 and 15 The facilities offered by the home enable the service users to maintain their preferred lifestyle; by maintaining links with their family and friends and the local community. EVIDENCE: During the inspection a number of service users expressed their views about living in the home, they felt that they were supported by the management and staff of the home to be as independent as possible and that they could be involved in activities in the home, if they wished. The home had a well stocked library, regular musical entertainment, exercise classes, religious services, illustrated talks from people in the local community, film afternoons and the hairdresser visited the home on a weekly basis. The home is currently planning the annual tea party that is due to take place on the 12th July 2005, many of the service users spoken to were looking forward to this event as they are able to invite family and friends to this event. The management and staff of the home are also planning a Christmas pantomime for the service users. The home encourages service users to maintain links with the local community and visitors are welcome at all times; it was noted that the home manger was available to visitors and took time to discuss any queries and concerns they may have had concerning the wellbeing of their relative or friend. The home employs an outside catering company to supply all meals to the service users; the menu seen was varied with plenty of choice; the menu is on Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 13 a four weekly cycle and is varied according to seasons, special diets were also catered for and food supplements were available. During the inspection, lunch was served in the communal dining room; service users were seated a tables of four and the manager of the home joined them for this meal, the atmosphere in the dining room was congenial and there was a lot of social interaction between service users and staff. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 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 standard(s) 16 and 18 The homes comprehensive policies, procedures and training relating to complaints and the protection of vulnerable adults, ensuring that service users feel safe and protected in their chosen environment. EVIDENCE: The complaints book was seen and currently there are no complaints being investigated under the home’s complaints policy and procedure. Each service user has a copy of this document and service users confirmed that they were aware of how to make a complaint; but stated that any concerns they had, were dealt with quickly and effectively by the home manager. From the training files inspected, it was evident that staff had received comprehensive training around adult protection issues; this training had been accessed via Bromley social services and BVS training videos and workbooks. The home had a copy of the Bromley guidelines relating to the protection of vulnerable adults and the home manager was aware of the legislation relating to the POVA register. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 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 standard(s) 19,20,24,25 and 26 The home provides a safe, comfortable, clean and well- maintained environment enabling service users to enjoy their preferred lifestyle. EVIDENCE: The home was maintained to a high standard; the home was clean and tidy and hygienic. Service users had comfortable single rooms decorated and furnished to their choice incorporating their own small pieces of furniture, ornaments, pictures and photographs. The communal areas, dining room, lounge and conservatory were well decorated and comfortably furnished retaining a home from home atmosphere for the service users. On the day of the inspection a number of service users were sitting in the conservatory and said that it was their favourite place to sit and read. The home has an extensive garden, accessible to the service users, the garden was very attractive and well maintained, with plenty of seating areas. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 16 The home has a comprehensive ongoing programme of refurbishment and re decoration, some of the bedrooms are in the process of incorporating en suite facilities. The home ensures the safety of service users with the provision of ramps for wheelchair users and the provision of handrails in the corridors, communal areas and the garden. The home has a well maintained passenger lift giving service users access to all areas of the home. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 17 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 and 30 The management of the home ensures that the staff are able to meet the service users needs by implementing thorough recruitment and selection and training policies and procedures. EVIDENCE: The staffing levels maintained by the management of the home ensure that there are sufficient staff with the appropriate skills, on duty, to meet the assessed needs of the service users. The home has robust recruitment and selection procedures and the inspection of six personnel files provided evidence that these processes were being followed; currently the personnel records are kept in a central file, it is recommended that each member of staff has their own file, incorporating an up to date photograph and a job description signed by the staff member. Whilst inspecting the personnel file it was noted that the application forms viewed only specified details of the present employer and did not ask for a full employment history; it was noted that enhanced CRB checks are undertaken for each employee, however there was no evidence to suggest that POVA checks had been undertaken for new employees. The home has a comprehensive training programme in place and the home manager has a designated budget for training. The individual training files showed that staff had undertaken induction training to TOPSS standards. Six staff members had achieved NVQ level 2 in care and two had completed NVQ level 3 in care; four members of staff were to commence NVQ 2 training at college. Staff had also completed mandatory training in moving and handling, basic food hygiene, health and safety and first aid. The home manager had Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 18 also arranged training in understanding difficult behaviour, dementia, infection control, diabetes COSHH, understanding sensory loss, medication, health and safety and adult abuse training. I Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 19 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) 31,32,33,36 and 38. The home has effective and efficient management and administrative systems in place, ensuring the stability of the home for both staff and service users. EVIDENCE: The home has a competent and experienced registered manager who understands the philosophy of the home and is able to meet its aims and objectives. From speaking to the service users, relatives and staff it was evident that they were listened to and that any concerns they had were acted upon and resolved quickly, they also said that the manager was accessible at all times. The home has a ladies committee who visit the home on behalf of the Schoolmistresses and Governesses Benevolent Institution, this committee had produced a quality of life questionnaire. The service users are able to complete the questionnaire and comment on the provision of care, the accommodation Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 20 and meals, their anonymity being preserved; any issues raised by the service users were addressed and resolved by the management of the home. The home maintained records appertaining to meetings held with the staff and service users, these meetings are forums for discussing issues about the home and for informing staff and service users of any forthcoming changes. The home had a supervision and appraisal system, however the supervision system is not fully implemented but the home manager is working towards complying with this standard. It was evident from documentation seen that each staff member has an annual appraisal. The home had robust policies and procedures relating to the health and safety of service users and staff in the home. Documentation viewed supported that the home complied with health and safety legislation. Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 21 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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 3 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 3 3 3 x x 3 x 3 Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 22 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 1 9 Good Practice Recommendations The home to provide the CSCI with the up to date brochure, when completed. The Registered Manager to make sure that an additions to the Medication Adminstration Record are hand written, labels from the pharmacist are not to be used on this record Each member of staff should have an individual personnel file, identified with a photograph and a copy of their job description signed by the staff members. The application form should give the staff members full employment history. The Registered Manager should make sure that every new employee has a POVA check. The Registered Manager should ensure that all staff members receive documented supervision on a regular basis. 3. 4. 5. 6. 29 29 29 36 Queen Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection Riverhouse 1 Maidstone Road Sidcup Kent 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 Mary House G51G01s38956QueenMaryHse.v215138.3.5.2005Stage4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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