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Inspection on 12/09/06 for Queen Mary`s and Mulberry House Nursing Home

Also see our care home review for Queen Mary`s and Mulberry House Nursing Home for more information

This inspection was carried out on 12th September 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required to enable them to make an informed choice about where they live. One resident said " I refer to it when I need to, I find it very helpful" some residents were not aware of the meaning. The atmosphere in the home was comfortable and relaxed. All parts of the home were clean, comfortable and well maintained. The quality and choice of meals remain good and all residents spoken with confirmed this. " The food is good" "we get a choice of food everyday" " the food is always freshly prepared".Systems are in place to regularly consult with residents via service users meetings and surveys. There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard resident`s finances. Staff provision is well maintained with good recruitment practice being followed and appropriate numbers of staff suitably qualified working in the home. The staff group on the whole is stable. Both residents and their relatives spoke highly of all the staff saying `staff are always nice and kind` `staff are helpful, approachable and are available to talk to`. The training for staff is good, and covers a wide variety of resident related conditions, which give the staff an understanding of the residents needs.

What has improved since the last inspection?

Recruitment files viewed demonstrated that robust recruitment procedures are followed for all new staff prior to employment. The nurse call system had been reviewed regarding the noise level.

What the care home could do better:

Medication practices at present do not ensure that the residents receive their medication consistently. Requirements have been made in regard to medication administration and storage shortfalls.

CARE HOMES FOR OLDER PEOPLE Queen Mary`s 7 Hollington Park Road St Leonards On Sea East Sussex TN38 0SE Lead Inspector Debbie Calveley Key Unannounced Inspection 12 September 10:00 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`s DS0000014031.V303898.R01.S.doc Version 5.2 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`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Mary`s Address 7 Hollington Park Road St Leonards On Sea East Sussex TN38 0SE 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) 01424-423692 Galleon Care Homes Limited Ms Julie Lowes Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (53), Physical disability (0) of places Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Old age, aged 65 years or over on admission, not falling into any other category (OP) People with a physical disability aged 50 years or over on admission (PD) Maximum number to be accommodated at any one time is 53 Date of last inspection 13th December 2005 Brief Description of the Service: Queen Marys is a large adapted house situated in a quiet residential area of St Leonards on Sea. A new purpose built wing was added to the home and completed in November 2004, increasing its registration numbers to 53. Bedroom accommodation is provided over three floors with shaft lifts fitted to ensure level access to all areas of the home for residents. There are large communal landscaped gardens and patio areas to three sides of the home. Local shops are approximately half a mile distance and St Leonards town Centre with its access to bus and rail routes approximately one mile away. Queen Marys is registered to accommodate up to 53 older people who may require nursing care, and adults aged over 50 years who may have a physical disability. Queen Marys is owned by Galleon Care Homes, who provide two other care homes within East Sussex. Copies of inspection reports and the homes Statement of Purpose are made available on request. Fees charged as from 1 April 2006 range from £457 to £676, which does not include personal toiletries. Additional charges are made for hairdressing, chiropody, newspapers and some outside activities such as visits to the theatre. Intermediate care is not provided. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Queen Mary’s will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 8 hours on the 12 September 2006. There were forty-eight residents in residence on the day, with two residents in hospital. Eight residents’ care notes were viewed as part of the inspection process and a further ten residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the service users guide, statement of purpose, care plans, medication records and recruitment files. Six members of care staff, two trained nurses, hairdresser and the cook & kitchen assistant were spoken with in addition to discussion with the Registered Manager. The pre-inspection questionnaire was received back from the registered manager on the 5 July 2006 completed in full. Comment cards received from six residents and two relatives were positive and indicated that both groups were satisfied with the services provided. Two comment cards were received from social and healthcare professionals, and eight staff surveys were received from a selection of staff. The information contained in the returned surveys has been incorporated into this report. What the service does well: The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required to enable them to make an informed choice about where they live. One resident said “ I refer to it when I need to, I find it very helpful” some residents were not aware of the meaning. The atmosphere in the home was comfortable and relaxed. All parts of the home were clean, comfortable and well maintained. The quality and choice of meals remain good and all residents spoken with confirmed this. “ The food is good” “we get a choice of food everyday” “ the food is always freshly prepared”. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 6 Systems are in place to regularly consult with residents via service users meetings and surveys. There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard resident’s finances. Staff provision is well maintained with good recruitment practice being followed and appropriate numbers of staff suitably qualified working in the home. The staff group on the whole is stable. Both residents and their relatives spoke highly of all the staff saying ‘staff are always nice and kind’ ‘staff are helpful, approachable and are available to talk to’. The training for staff is good, and covers a wide variety of resident related conditions, which give the staff an understanding of the residents needs. 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`s DS0000014031.V303898.R01.S.doc Version 5.2 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`s DS0000014031.V303898.R01.S.doc Version 5.2 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): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The pre-admission assessment procedures ensure residents admitted can have their care needs met within the home by experienced staff. EVIDENCE: There is a range of well-documented information about the home and the services it provides. This includes a statement of purpose and service user guide. Copies of these are available in the main lounge area and on request. Two residents however did not have any knowledge of the brochure and it might be beneficial to remind residents of its existence at the next resident meeting. A social care professional, who had recently visited the home, confirmed that relevant information was provided to a prospective resident. It was confirmed whilst talking to residents that the contract arrangements were clear and understood. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 9 A review of the care documentation confirmed that pre-admission assessments are completed, and are currently completed by the manager or a senior nurse. Seven of the eight assessments were found to be completed in full and were used to ensure new admissions to the home were suitable and that the home have the staff and environment to meet the care needs of the new resident. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representative is involved. Two relatives confirmed that they were consulted about the pre-admission visit and were given the opportunity to attend. The manager was able to verbally demonstrate her knowledge and awareness of the different specialities required in the home and ensures that the Registered Nurses employed have attended relevant courses to deal with the needs of the elderly and also specialised courses for certain diseases. Trial visits to the home can be arranged. The manager confirmed that all residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 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 and 10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Generally care plans provide a good framework for the delivery of care, however these need to provide clear guidance to care staff on all the care needs of all the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. However medication practices at present are not protecting residents. EVIDENCE: The care documentation pertaining to eight residents were reviewed as part of the inspection process. These were found to include plans of care, nutritional assessment, personal histories and risk assessments. On the whole the care documentation was full and demonstrated that the care was reviewed and evaluated, however it was noted that the plans of care did not always cover the communication problems of residents and did not have any guidance in the documentation to facilitate this vital need. Staff spoken to confirmed that they received a full report on each resident daily and read the care documentation that is kept in a locked container in the Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 11 corner of the main lounge area. The staff felt that their views were taken into account when planning and implementing resident’s care. The clinical room was found to be very crowded and as a result untidy, however it was confirmed that this will be addressed when the extension is completed. All the cupboards and clinical fridges were appropriately locked. The storage and staff maintenance/cleaning of equipment needs to be improved to ensure equipment is clean and ready for use. The sharps bin in use was filled to the brim and staff are at risk from a needle stick injury. There are policies and procedures in place for the storing, administrating, disposal and receipt of medication; they were last reviewed in April 2006. The temperature of the fridge and room are recorded daily and of an acceptable temperature to maintain dressings and medications. There are medications in the fridge that need to be dated on opening, as they have a short life span. Asthmatic inhalers were found unlabelled on a tray in the clinical room. A thorough review of topical prescribed medications needs to take place as some residents had two or three topical creams/lotions in use in their roomspresumably all in use, one resident had creams in her bathroom which according to staff and her medication chart are no longer being used on her condition. The medication administration charts were viewed and gaps were identified, The development of an internal medication audit would be beneficial to identify and prompt appropriate action to deal with poor practice issues. A recommendation of good practice is that an index for controlled medicines is re-introduced, which would allow staff to find the correct page for each resident medication immediately rather than going through the whole book. Resident photographs on the medication administration records were discussed as a safety precaution for new or agency staff, the manager confirmed that new staff or agency staff will not be responsible for a medication round or if they were, then a senior carer would accompany them to prevent any errors with dispensing. Throughout the inspection it was observed that residents were treated with dignity and respect. One relative said that “ the staff always show respect to residents and nothing was too much trouble”. A resident remarked that” she felt the staff respected her feelings and that she never felt she was a nuisance”. Two relatives said, “the care their relative received was very good and the staff were always very kind and respectful”. Another relative said the “care could not be better”. One resident and his wife said that the “staff were great and they were treated with thoughtfulness and kindness at all times”. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Social activities and meals continue to be creative and provide variation and interest for people living in the home. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. EVIDENCE: The routines of daily living are flexible as possible, and residents choose their daily schedule when they are able to, including their meal times and venue. Feedback from six residents and from direct observation on the day, it was apparent that residents are given the opportunity to spend their time as they wish. There is one activity co-ordinator employed and one assistant co-ordinator and activity sessions take place three times a week. Activities include baking, gardening, trips out, clothes parties, music and reading sessions and craft work. There are regular one to one sessions for those residents that do not attend activities and this could include trips out in a car, shopping trips or just a chat in their bedroom. The care plans illustrate their individual social needs and how the staff meet them. The inspection took place on a day where no activities were planned, however residents feedback was positive regarding the activities provided, three residents said they did not always attend, but enjoyed the sessions they did go Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 13 to. Another said they chose not to attend, but they were always given the opportunity to change their mind. The comments from surveys received included, “ There are two ladies that spend time with us, and often we have visitors to talk to us, girls dancing, children singing, and vicar services” “ Very caring and conscientious and they try” “ a wide variety from visits, expeditions, handcrafts and games and visiting professionals coming here”. Residents are facilitated to maintain their independence for as long as they are able. There are no restrictions on visiting times as long as consideration is shown to all the residents. Two relatives commented on how friendly and caring the staff are. The lounges on both floors are available to residents and their visitors for private meetings if required. The menus are distributed to all residents and are also on display in the dining rooms. They demonstrated choice and variety and indicated a well balanced diet. The menus rotate on a four weekly basis and change according to the seasons. Fresh fruit is available. The second cook was on duty on the day of the inspection. The inspector observed the midday meal, and the food prepared was attractively presented and enjoyed by the residents, a choice of food was available. The pureed diet was the same as the main menu and when served to residents it was also attractively presented. The residents were forthcoming in their views of the food, and the majority said the choice was varied and the food was very good. One resident said, “ the food is very good, no complaints”. Another said “ not bad”, one resident did mention that porridge everyday was not her choice and would like bacon and eggs, however other residents confirmed that they could have a cooked breakfast everyday. The dining area is pleasant and well furnished with natural light. The kitchen was clean and well organised, and good practice was observed with serving up and distributing the meals. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 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 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Procedures in the home ensure that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has a clear complaints procedure and a copy of this is readily available in the home. There has been one complaint received internally since the last inspection, which was fully investigated using the homes procedure and was found not substantiated. Relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and have participated in strategy meetings in the past. Staff spoken with were able to discuss the adult protection procedures in place and were aware of the whistle blowing policy. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: Queen Mary’s’ provides a well-maintained and comfortable environment for its residents and for those visiting. Building work has been commenced for the extension and care has been taken to ensure that the residents’ lifestyle is not impacted on during this time. There are adequate communal bathrooms and shower rooms in the home with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. Call bells are provided in all areas, however not Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 16 all residents in the lounge had access to a call bell and residents said that they just called out when they needed some one. This might not be practical and safe for those residents that do not have the capacity to call for help, however staff were seen checking the lounge regularly throughout the afternoon. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Beds and chairs were seen to be placed appropriately for maximum benefit of those wishing to read. Water temperatures are controlled and monitored monthly and a record kept. Random temperatures were taken and were of the recommended level. The storage of showerheads and the Legionella guidelines in place were discussed, and the home are to seek further clarification from the organisation regarding the policies and procedures currently in place. There was evidence of residents being encouraged to personalise their rooms with their own belongings and bits of furniture. The bedrooms are clean, comfortably furnished and pleasantly decorated with soft colours. One resident said “ the cleaning ladies are good, they are not intrusive” another said “the cleaning is always first class”. A relative said, “She could not fault the cleanliness and comfort of the home”. Survey comments included, “ a very high standard of cleanliness” “ domestics do a good job and laundry does well”. Polices and procedures for infection control are in place and are updated regularly, last review was dated 01/08/05. The home was clean and free from offensive odours in all areas on the day of the inspection. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. Sluice and laundry areas were found clean and safe. The home provides a good laundry service and all residents were observed to be well dressed. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 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 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 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Staff spoken to said that the levels of staff on duty were sufficient to give the care required, they also said that the trained staff always helped out. Residents also confirmed that they had no complaints regarding the amount of staff, one resident said the “staff are always helpful, they look after me very well”. Another said, “ The staff are really nice, always take time to talk to me”. “Sometimes a little delay in answering my call bell, but they always came as soon as they can” Staff files of five employees were viewed and evidenced that the home management team follow robust procedures when employing staff. They contained the required information and demonstrated that the appropriate induction training had been completed in respect of the job they were to undertake in the home. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 18 Staff interviewed confirmed a high satisfaction with the training provided and stated that recent training was interesting and informative. Six staff surveys received stated that they were satisfied with the standard of training provided. Staff and records seen confirmed that they had undertaken compulsory training such as manual handling, adult protection, and fire safety. In addition specialist training in understanding dementia, palliative care, care of the dying, pressure sore management and stroke care updates are also provided. NVQ training is available and staff are encouraged to complete this, at present 40 of staff have an NVQ qualification. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 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 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): 31, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The overall management of this home is good with effective systems in place to protect residents. EVIDENCE: The Registered Manager is a Qualified Registered General Nurse and has the experience to run the home effectively with support from her team of staff. A deputy manager completes the management team. The management structure of the home is strong, competent and has clear lines of accountability. The feedback from residents, relatives and staff indicated that they felt supported and were able to approach the management team at any time. The ethos of the home is to focus on the residents and the staff were observed doing this. Regular staff meetings and resident/relative meetings are held and records of the meetings are kept. The staff surveys mentioned the staff meetings and how beneficial they were and the staff felt that areas of Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 20 improvement they put forward were acted for the benefit of the residents. These form part of the quality assurance systems in the home. One resident mentioned that they attended the resident meetings and thought it gave them the opportunity to discuss the running of the home and areas that could be improved. Residents’ financial interests are safeguarded by the homes policies and procedures. All staff spoken with were aware that they must not be involved in any financial matters of the residents, they also said that they would not accept money or gifts from residents. The residents spoken with said they had no worries regarding their financial status, and felt they were supported in managing their affairs efficiently. The manager confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies, the manual is available to all and clearly defined. Staff were able to discuss the training they received and said that they were kept up to date with changes to policies in connection with fire safety and health and safety. The staff are issued with certificates yearly for Manual Handling, infection control and twice yearly for Fire Safety. It was discussed that all care staff and trained staff that are involved with serving food and assisting residents to eat would benefit in receiving basic training in food and hygiene, further clarification was to be sought. The home has a comprehensive set of policies and procedures, which govern the running of the home. All relevant legislation and procedures are in place in respect of Health and safety. Evidence was seen of regular supervision sessions and all staff spoken with and those that completed staff surveys confirmed that they receive regular supervision. Throughout the inspection good practice was observed in regards to ensuring the safety and well being of the residents when being moved around the building. The accident forms were seen and had been correctly completed with appropriate referrals made as necessary. As mentioned previously staff need to ensure that all residents have access to a call bell facility in communal areas. Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13 (2) Requirement Medication administration record charts must reflect current medication profile and must be a true and accurate record. That all verbal orders for medication follow the homes procedures with dates and signatures of the persons responsible for taking the order. Medication that has a short life span needs to be dated on opening. That an audit of the medication charts is developed. Health and Safety: That procedures regarding of the sharps bins and needle disposal are followed. That health care equipment for use of service users are maintained and stored appropriately. Timescale for action 12/10/06 2 OP38 13 (4) 12/09/06 Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen Mary`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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`s DS0000014031.V303898.R01.S.doc Version 5.2 Page 25 - 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!