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Inspection on 13/12/05 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 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

Queen Mary`s is a well-run nursing home that places its residents at the heart of the service. It employs satisfactory numbers of suitably trained staff to meet the assessed needs of residents. Residents` comments included: `I`m perfectly satisfied` and `I can`t fault it, it`s brilliant`. The home is immaculately maintained throughout.

What has improved since the last inspection?

The home has worked hard to meet all of the requirements from the previous inspection report. Residents are kept informed of their changing needs and their feedback has been sought with regards to the quality of the care that is provided. All doors within the home are now fitted with automatic fire door closures.

What the care home could do better:

The home needs to ensure that thorough recruitment checks are carried out for all new staff prior to employment. This will help to ensure residents` safety. The nurse call system is currently very loud; this needs reviewing alongside residents whilst maintaining their safety.

CARE HOMES FOR OLDER PEOPLE Queen Mary`s 7 Hollington Park Road St Leonards On Sea East Sussex TN38 0SE Lead Inspector Niki Palmer Unannounced Inspection 13th December 2005 11:45 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.V270005.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`s DS0000014031.V270005.R01.S.doc Version 5.0 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.V270005.R01.S.doc Version 5.0 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 8th August 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. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 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, uses 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 unannounced inspection took place on Tuesday 13th December 2005 between 11:45am and 3:45pm. The inspection began by having discussions with the Deputy Manager and administrator of the home in respect of progress made since the last report, followed by an inspection of the premises and its facilities. In order to gather evidence on how the home is performing, individual discussions took place with five residents, two nursing staff, two care assistants, a maintenance person and four visiting relatives. 52 residents were accommodated at the time of the inspection. Other records and documentation inspected included: the home’s Statement of Purpose and Service Users’ Guide, three individual care records, the home’s complaints procedure, quality assurance systems, three staff recruitment files and a number of health and safety checks. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection report carried out on 8th August 2005. What the service does well: What has improved since the last inspection? The home has worked hard to meet all of the requirements from the previous inspection report. Residents are kept informed of their changing needs and their feedback has been sought with regards to the quality of the care that is provided. All doors within the home are now fitted with automatic fire door closures. Queen Mary`s DS0000014031.V270005.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`s DS0000014031.V270005.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`s DS0000014031.V270005.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): 1. Residents are provided with sufficient information to help them judge if the home is appropriate for them. EVIDENCE: The home has compiled a detailed information folder, which contains the updated Residents’ Guide and Statement of Purpose. This is kept in the front lounge of the home, which is easily accessible for visitors and existing residents. At the front of the folder is an introduction written by the Registered Manager of the home. It states that ‘Queen Mary’s residents’ guide has been compiled to help relatives and residents to choose the right home’. It contains details of the terms and conditions of contract, room details, residents’ charter, a copy of the home’s most recent inspection report, the complaints procedure, local health services and residents’ views and comments. All residents and relatives spoken with confirmed that they had found the literature helpful. It was pleasing to note that one of the relatives spoken with had read the home’s most recent inspection report on the Internet. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 9 Two of the relatives said that they had initially just called in to the home unannounced to have a look around. They said that this gave them the opportunity to see the home ‘as it is’. They said that the staff were very welcoming, helpful and ‘not pushy’. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10. Residents’ are kept informed of their changing healthcare needs and are treated with kindness, dignity and respect. EVIDENCE: Three individual plans of care were seen over the duration of the inspection. Although there was little evidence that care plans had been shared with residents and/or their relatives, residents spoken with confirmed that nursing staff do keep them updated and informed of any changes. The Deputy Manager advised that letters have recently been sent out to relatives of residents who are unable to agree and sign their own care plans in order to ascertain the level of involvement they wish to have in the reviewing of care plans. Residents confirmed that staff treat them at all times with dignity and respect. Each of the residents are addressed by their preferred term and have all personal care needs carried out in the privacy of their own rooms or bathrooms. ‘Care in progress’ notices are placed on all bedroom and bathroom doors at this time. Residents confirmed that care staff do always knock and are on the whole very good in maintaining their privacy and dignity. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 11 Throughout the course of the inspection all staff were observed to treat residents appropriately, from nurses and care assistants to housekeepers and administration staff. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Whilst on the whole residents are offered a variety of choice and control over their lives, they are not always encouraged to maintain their independence. EVIDENCE: The vast majority of residents spoken with said that the nursing and care staff encourage them to take some level of control and choice over their lives particularly in relation to the daily routines. Residents’ preferences are recorded within their plans of care for example their preferred time, choice of going bed and getting up in the morning, their meals and chosen activities. Residents can choose if they wish to have breakfast in bed. One resident commented that staff tell him when to bathe and shower, and which clothes to wear. A requirement has been made for the home to ensure that all residents are offered choice and encouraged to maintain their independence. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. The home has good systems in place to ensure that all complaints will be handled appropriately. EVIDENCE: The home has a detailed complaints procedure on display in the main entrance area of the home. This has been produced in a larger font size in order to make it more visible and readable. A record of all complaints made to either the home or the CSCI are kept. No complaints have been made since the last inspection. Residents and relatives spoken with did say that they were informed of the complaints procedure on admission, but many said that they could not ever imagine having to make a complaint. This was very pleasing to hear. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 22. Whilst Queen Mary’s provides residents with a safe, comfortable and wellmaintained place to live, it does not present as quiet and peaceful. EVIDENCE: Queen Mary’s care home comprises of 51 single bedrooms – 45 of which have en-suite facilities, and one double room also with en-suite. The home is wellmaintained throughout both internally and externally by a number of domestic staff and a full-time maintenance person. Communal areas are provided on the ground floor and are furnished and decorated to a high standard. Many of the residents and their relatives commented on the fact that the home is always clean throughout and presents as homely and attractive. On the day of inspection it was noted that the nurse call system was particularly loud. One resident did complain to the Inspector that she finds it most disturbing and irritating. The Deputy Manager explained that if the alarms were any quieter, care staff would not be able to hear them from Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 15 certain areas of the home. The home is required to review the nurse call system in consultation with residents. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 29. Whilst residents are supported by suitably trained staff, the standard of vetting and recruitment practices are inadequate. EVIDENCE: All of the residents and relatives spoken with were very positive of the nursing and care staff. Comments included: ‘can’t fault any of them’, ‘perfectly satisfied’ and ‘the staff are very good, particularly the young men’. Of the 19 care assistants employed by the home, six are trained to at least NVQ level two, two are currently working towards this and a further two are due to enrol with a local college before Christmas. Three of the most recently employed staff recruitment files were checked for compliance with the Regulations. Whilst there was evidence of a PoVA First and Criminal Record Bureau (CRB) being obtained prior to employment, one file only had one written reference and in another there was no photo identification. A requirement has been made in respect of this. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 17 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, 33 and 38. The Registered Manager is supported well by the senior staff. This ensures that the home is run effectively and in the best interests of residents. EVIDENCE: The Registered Manager has been in post for over two years. All of the residents, relatives and staff spoke highly of her leadership and management skills. An experienced Deputy Manager supports her in her role. Either one or the other is usually on duty. They both have their Registered Managers Award. Since the last inspection questionnaires were compiled in order to gain feedback from residents and others regarding the overall care services provided at Queen Mary’s. These were sent to all residents, a visiting hairdresser, chiropodist, local General Practitioners and the Community Mental Heath Team. The returned responses are currently at the home’s head office for analysis. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 18 A maintenance person is employed on a full-time basis over five days a week. He has recently attended a health and safety course to support him in his role. A number of maintenance checklists were seen on the day of inspection. All were found to be complete and up to date. Since the last inspection all doors have been fitted with automatic fire door closures. Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X 2 X 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 3 X 2 X X X X 3 Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 20 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. 2. 3. 3. Standard OP14 OP22 OP29 OP33 Regulation 12(2)(3) 16(1) (2)(c) 19 & Sch 2 24(1)(a) (b) Requirement That all residents are offered choice and are empowered to maintain their independence. That the nurse call system is reviewed in consultation with residents. That thorough recruitment checks are carried out prior to the employment of all new staff. That the results of the recent residents’ and others questionnaire are published and made available. Timescale for action 31/12/05 31/03/06 13/12/05 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen Mary`s DS0000014031.V270005.R01.S.doc Version 5.0 Page 21 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.V270005.R01.S.doc Version 5.0 Page 22 - 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. 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