Inspection on 29/11/05 for Queen Mary House

This inspection was carried out on 29th November 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 02/05/05

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 Inspection 29th November 2005 10:30 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 Mary House DS0000038956.V259535.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 Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Queen Mary House Address Manor Park Road Chislehurst Kent BR7 5PY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8467 3112 School Mistresses and Governesses Benevolent Institution Susan Perry Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd May 2005 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, benefiting 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 DS0000038956.V259535.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced statutory inspection for this home; the inspection took place over four hours and comprised of a tour of the home, an inspection of the Medication Administration Records, personnel, training, supervision and appraisal records for staff, as well as resident’s financial records. The activity and entertainment plans were seen and commented upon by residents spoken to during the inspection. There were no visitors to the home at the time of the inspection; however two residents were spoken to in detail and six members of care staff, the manager, the deputy manager and the administrator. What the service does well: What has improved since the last inspection? The personnel files now have a photogragh of the employee and a job description signed by the employee; the application form should include a full employment history and each employee should have an individual personnel file to be able to comply with the Data Protection Act 1998. Supervision and appraisal systems are in place; however this needs to be more structured and recorded and there should be at least six supervision seeions annually The new brochure has now been completed, and is awaiting authorisation and printing. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 6 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 DS0000038956.V259535.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 Mary House DS0000038956.V259535.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): None EVIDENCE: Standards one to five were assessed at the previous inspection on 2nd May 2005, and were met. Standard six is not applicable to this home. The new brochure for the home has been completed and is awaiting printing, the Commission will receive a copy as soon as it is available. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 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 the following standard(s): 9 The medication policies and procedures of the home ensure that the residents are protected by the way in which medication is recorded on the Medication Administration Record. EVIDENCE: All the standards in this section of the report were comprehensively assessed at the previous inspection on 2nd May 2005, and were met. A recommendation made in respect of standard nine, relating to the Medication Administration Record, this issue has now been addressed and is therefore met. The Medication Administration Records were checked at this inspection, and there were no instances of labels from the pharmacy being used; all MARS sheets are now computer generated, ensuring that the residents receive the correct medication, in the correct dose at the correct time. Therefore the risks associated with the administration of medication are minimised. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 10 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): 12 and 13 Activities and entertainments provided by the home are creative and of a high standard, ensuring that the residents’ social, cultural, religious and recreational expectations are satisfied. EVIDENCE: Standards twelve and thirteen were assessed in the previous report and were met; during this inspection it was noted that the provision of activities and entertainment in the home exceed standard 12; and the home is to be congratulated on the standard of activities and entertainment available within the home. The residents spoken to at the time of the inspection were very appreciative of the variety of activities and entertainments on offer and were looking forward to the extensive entertainment planned for the Christmas and New Year period; this included a pantomime put on by the staff and management, a Christmas party for residents, their family and friends, a church service of carols and readings and of course Christmas lunch. The residents stated that the annual tea party held on the 12/07/05, was a success and that they enjoyed the event; the home has an activities and entertainment programme throughout the year including exercise classes, musical entertainers coming into the home on a regular basis, religious services and illustrated talks from people in the local community. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 11 Standards fourteen and fifteen were assessed in detail in the pervious report of 2/05/2005, and were met. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 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 the following standard(s): 17 The home ensures that the residents’ legal rights are protected by making sure that the residents have access to a local advocacy services and are able to exercise their right to vote in general and local elections. EVIDENCE: Standards sixteen and eighteen were comprehensively assessed at the previous inspection on 2/05/05, and were met. Standard seventeen was assessed at this inspection and was met. The home manager has access to the Bromley Advocacy Service, and there are leaflets available currently none of the residents avail themselves of this service. In discussion with the home manager, the residents have the opportunity to vote in local and general elections, if they are able arrangements are made for the residents to attend the local polling station or a postal vote application is made on behalf of the resident. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 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 the following standard(s): 21,22 and 23 The home provides sufficient and appropriate lavatories and bathrooms, specialist equipment and bedrooms to suit the residents’ assessed health, personal and social needs. EVIDENCE: A tour of the premises was undertaken on the day of the inspection and toilets and bathrooms were checked and were found to comply with standard 21; toilets were equipped with grab rails and raised toilet seats if needed and there are three parker baths for the use of residents with impaired mobility. The home is able to access specialist equipment via the GP, District Nurse and a local medical loan service. Pressure relieving equipment, including mattresses and cushions, are in place in the eight bedded high dependency unit as are hospital type, height adjustable beds. Mobility aids such as wheelchairs, zimmer frames and walking aids are accessed via Bromley Primary Care Trust with input from physiotherapists and/or occupational therapists. The home has two, electric, regularly serviced, hoists to aid residents with mobility difficulties. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 14 It was evident from visiting residents in their bedrooms, that the rooms suited their assessed health personal and social needs. The bedrooms seen complied with standard 23 regarding dimension and layout, rooms were well decorated and furnished, with the residents personal belongings, ornaments, photographs, pictures and small items of furniture. It was noted during the inspection and a conversation with the maintenance person, that there are plans to convert bedrooms to en-suite; two rooms were seen and had been completed. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 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 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): 28 and 29. The home has achieved 50 of trained members of care staff qualified to NVQ 2 or equivalent; ensuring that the residents are in safe hands at all times. The home needs to review the way personnel files are organised so that they comply with schedule 2 of the National Minimum Standards –Care Homes Regulations and the Data Protection Act 1998. EVIDENCE: Records were checked and evidenced that eight care staff had successfully completed NVQ 2, two members of staff have completed NVQ 3, both the Home Manager and Deputy Manager have completed the Registered Managers Award. One member of staff is currently doing NVQ 3 and the RMA and one member of staff is to commence NVQ 3 in Jan 2006. Standards twenty-seven and thirty were comprehensively assessed at the previous inspection on 2/05/2005, and were met. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 16 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): 34,35 and 37. The homes’ financial and accounting policies and procedures demonstrate that the residents’ financial interests are safeguarded and protected. The homes’ record keeping, policies and procedures ensure that the residents’ rights are protected. EVIDENCE: The insurance certificate is displayed in the home in a prominent position in the foyer, along with the Certificate of Registration; both these certificates contained current information and were in date. The residents’ personal accounts were checked, with the homes’ administrator, were found to be correct. All residents have an individual leger sheet that is completed for every financial transaction, when monies are required by the resident the leger sheet is sent to the resident or next of kin or appointee/solicitor; receipts are kept for all monies spent and the residents Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 17 cash is kept in an individual wallet; two members of the administration staff check and balance the accounts and cash on a weekly basis. Fees are paid to the home either by standing order or bankers draft; an invoice is sent to the person responsible for payment by the homes’ administrator. The home manager has control of petty cash, accurate records and receipts are kept for auditing purposes. All invoices for goods and services are documented and paid directly by the home. The home has a comprehensive business and financial plan that was sent to the Commission as requested, this plan demonstrates the financial viability of the home and business. The homes’ record keeping and policies and procedures that are required by regulation for the protection of residents and for the effective running of the business are maintained, up to date and accurate. However a requirement has been made relating to the compilation of personnel records this matter should be addressed and resolved by 31/01/2005 and the Commission advised when this is completed. Standards 31,32,33,36 and 38 were assessed in detail at the previous inspection on 2/05/2005, and were met. A recommendation was made in this report relating to supervision and appraisal, the home manager is currently addressing this issue; therefore the recommendation will remain on the report until evidence supports the regularity and documentation of supervision. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 x X X 3 3 3 X X X STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 X 3 X Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 29 Regulation 19 Requirement The Registered Person must make sure that employees of the home complete an application form giving specific details of previous employment. Timescale for action 31/01/06 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 OP1 Good Practice Recommendations The home to provide the CSCI with the up to date brochure, when completed. 6. OP36 The Registered Manager should ensure that all staff members receive documented supervision on a regular basis. Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen Mary House DS0000038956.V259535.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!